The Elderly Care Report: The True State of Aging in America

According to the U.S. Census, over 61 million Americans are now aged 65 and older, with older adults accounting for more than one in five residents in several states.¹ This growing population is driving demand for affordable healthcare, long-term support, and home-based services.

However, the experience of aging varies widely depending on where people live. Our report finds that northeastern states such as Vermont and Maine face some of the highest care pressures, fueled by aging populations and costly home health services exceeding $100,000 in parts of the U.S., while states like Louisiana and Texas provide comparatively stronger affordability and service availability.

At Opera Beds, we believe dignity, safety, and independence should not depend on geography. For families exploring ways to support aging at home, options such as hospital beds for your home can help improve comfort, mobility, and caregiver support.

This report highlights both the states under the most pressure and those with stronger systems, offering a clear comparative view of America’s aging care landscape.

Key takeaways

• Seniors in Hawaii live longer than anywhere else in the U.S., but the state also faces some of the highest care costs and limited support infrastructure.

• Maine and Vermont have some of the oldest populations in the country, intensifying demand on local care systems.

• In Nebraska, nearly 22% of adults aged 65+ report struggling to pay off medical bills.

• Hiring a home health aide now costs over $100,000 per year in South Dakota, the highest in the country.

• Iowa has nearly five times as many nursing homes per senior as some states, highlighting major regional gaps in care infrastructure.

• Aging is a zipcode lottery, with factors such as healthcare availability, infrastructure, and demand for services varying greatly by state.

The most challenging states for seniors

To understand where seniors face the greatest challenges, we created an Elderly Care Pressure Score out of 10 for each state, combining five equally weighted factors:

• Percentage of residents aged 65+

• Medical bill affordability

• Annual home health aide cost

• Medicaid-certified nursing homes and home health services per 100,000 adults aged 65+

• Life expectancy at 65

1.  Vermont – elderly care pressure score 8.36/10

Vermont ranks as the most pressured state for aging in the U.S., with more than one in five residents (20.8%) aged 65 and over - one of the highest shares nationally. This drives strong demand for both institutional care and home-based support.

Care capacity remains relatively limited, with 25.3 nursing homes per 100,000 seniors (below the national average of 30.2) and just 6.7 home health services per 100,000. Meanwhile, the average annual cost of a home health aide is $99,528, significantly higher than the U.S. average of $80,035.

Residents aged 65 in Vermont can expect to live to 84.5 years on average. While longer life expectancy reflects strong health outcomes, it also extends the period during which families may need long-term care and financial support.

2. Hawaii – elderly care pressure score: 7.94/10

With a life expectancy at age 65 of 85.5 years, the highest in the country, residents can expect to live, on average, an additional 20.5 years after turning 65.

Care infrastructure is limited, with 14.6 nursing homes and 5.6 home health services per 100,000 older adults, both below national averages. Home health aides cost $97,240 annually, over $17,000 above the U.S. average.

While just 7.5% of adults aged 65 and over report difficulty paying medical bills, the extended lifespan and high living costs mean Hawaii residents face a high long-term financial burden.

3. Maine – elderly care pressure score: 7.62/10

Maine has the largest 65+ population in the nation at over one in five people (21.9%). This creates structural pressure on support systems.

Home health aide care costs $98,384 annually, while 14.6% of seniors struggle with medical bills, compared to the 11.8% average. Nursing homes sit at 25.9 per 100,000; however, access is limited in rural areas.

Life expectancy at 65 in Maine is 83.7 years. With more than one in five residents aged 65+, maintaining long-term infrastructure is an ongoing challenge.

The most supportive states for aging adults

1. Louisiana - elderly care pressure score: 1.58/10

Louisiana has the lowest overall elderly care pressure score. Home health aide costs average $50,336 annually, making them among the most affordable in the country. With 35.3 nursing homes per 100,000 older adults, Louisiana's care infrastructure is higher than in many other states.

Louisiana’s affordability and service capacity help reduce the overall strain on aging citizens, even though some challenges remain.

2. Texas – elderly care pressure score: 2.82/10

With only 13.2% of its population aged 65 and over, Texas faces lower demographic pressure than some northeastern states.

The state's home-based infrastructure is strong, with 47.3 home health services per 100,000 seniors, well above the national average of 30.2. While 14.4% of Texas seniors face financial strain from medical bills, higher than the national average of 11.8%, the availability of care helps offset some of this pressure.

3. Arkansas – elderly care pressure score: 2.94/10

Arkansas has a strong care capacity, with 42.0 nursing homes, compared to the 30.2 average, and 17.5 home health services per 100,000 seniors. Annual home health aide costs are $59,488, significantly lower than in high-pressure states and almost $21,000 below the US average.

While 11.7% of seniors in Arkansas report difficulty paying medical bills (just below the national average of 11.8%), the affordability of services like home aides can help reduce overall strain on systems.

Healthcare affordability for seniors

To assess healthcare affordability, we analyzed the percentage of adults aged 65 and over who reported having trouble paying off medical bills in the past year. Data is sourced from the State Health Access Data Assistance Center (2019-2023), which tracks state-level financial strain among older adults, including those covered by Medicare.

While Medicare provides essential coverage, it does not eliminate out-of-pocket expenses such as deductibles, co-insurance, prescription drugs, dental care, and specialist visits.

Financial strain is most significant in parts of the Midwest and Mountain West. 

In Nebraska, over one in five (21.9%) adults aged 65+ report difficulty paying medical bills, the highest rate nationally. Wyoming follows at 18.4%, where rural healthcare access challenges may increase cost, especially when specialist care requires long-distance travel. South Dakota ranks third at 16.8%, and when combined with the state’s high long-term care costs, this increases financial vulnerability.

Home health aide care costs by state

To evaluate long-term care affordability, we used 2025 cost data from CareScout, which tracks the average annual cost of full-time home health aide services. These aides support daily living activities, including bathing, dressing, mobility, and medication management.

The highest costs are seen in smaller, more rural states with aging populations. 

South Dakota records the highest annual home health aide cost in the nation at $100,672, and is the only state to surpass the $100,000 mark. Vermont follows closely at $99,528 annually, straining one of the country’s largest senior populations. Maine ranks third at $98,384, highlighting the high costs faced by the nation’s largest share of residents aged 65+.

Nursing homes and home health services per 100,000 seniors

Care capacity was assessed using provider data from the Centers for Medicare & Medicaid Services Care Compare database, normalized by each state’s population aged 65+. By doing this, we compared infrastructure to demographic demand rather than focusing solely on total facility counts.

 

Midwestern states dominate in the availability of institutional care. 

Iowa leads with 68.7 nursing homes per 100,000 seniors. South Dakota follows with 61.4 nursing homes per 100,000 seniors, showing that while home health aide costs are high, the capacity for care is strong in comparison. Kansas ranks third at 61.0 per 100,000, helping to show a regional pattern of more nursing homes per population in the Midwest. 

Strong infrastructure reduces the risk of demand outpacing available facilities, although affordability pressures may still limit access for some households.

Where are seniors living the longest?

Life expectancy at age 65 was sourced from the Centers for Disease Control and Prevention National Vital Statistics Report. This measure reflects the average number of additional years a 65-year-old can expect to live.

Life expectancy at 65 is highest in coastal and northeastern states. Hawaii ranks first, with residents aged 65 expected to live to 85.5 years, almost two years longer than the national average. Connecticut and New York follow closely at 84.8 years. 

A longer life expectancy generally indicates strong healthcare systems and better socioeconomic conditions. It also means some people may need medical, financial, and mobility support for longer as they age.

Size of the elderly population

To measure demographic pressure, we analyzed the percentage of residents aged 65 and over using the 2023 five-year estimates from the US Census Bureau American Community Survey. States with larger older adult populations face increased demand for healthcare services, long-term care, and age-friendly infrastructure.

 

Maine ranks first, with over a fifth (21.9%) of its population aged 65+, totaling 301,161 seniors in a population of just 1.37 million. This creates high demand for senior care services. Florida follows at 21.1%, representing 4.63 million older residents and reflecting its appeal as a retirement destination. Vermont ranks third at 20.8%, reinforcing the demographic pressure identified in its overall elderly care score.

Geographic inequality in aging

Northeastern states such as Maine and Vermont have large senior populations and high care costs. Retirement destinations like Hawaii combine long life expectancies with limited per-capita availability of facilities. Meanwhile, parts of the Midwest provide strong nursing home capacity but face affordability pressures.

These regional differences demonstrate that aging is influenced by cost structures, infrastructure density, and lifespan trends that interact differently across states, producing distinct patterns.

What this means for older Americans

The true cost of aging includes a growing senior population, access to the same care, infrastructure availability, life expectancy, and long-term care costs.

Some states have systems better prepared to meet the needs of an aging population. In others, high costs and concentrated demographics make it harder to access care.

As the 65+ population continues to grow, a trend confirmed by the US Census Bureau¹, ensuring equal access to affordable care could be a challenge that impacts where you choose to live.

Methodology

We ranked each US state on the following factors:

1. Size of the elderly population: The percentage of residents aged 65 and over, sourced from the US Census Bureau

2. Healthcare affordability: Percentage of adults aged 65+ who had trouble paying off medical bills in the past year, sourced from State Health Compare

3. Cost of long-term care: Average annual cost of home health aide care, sourced from Carescout

4. Care capacity: Nursing homes sourced from CMS, and home health services sourced from CMS. We normalized this against the population of people aged 65 and above. 

5. 65+ life expectancy: Sourced using CDC and added to the age 65 to show life expectancy at 65

We put this data into a weighted table to normalize each factor with a score out of 10. We then calculated an average of these scores to get our overall Elderly Care Score out of 10. Where data for a metric was unavailable, the state’s score was calculated based on the remaining available factors.

Sources

1. https://www.census.gov/newsroom/press-releases/2025/older-adults-outnumber-children.html