Advances in medicine have extended life for millions of Americans, but longer lives often come with a price: a higher likelihood of chronic illness or physical or cognitive impairment.
Much of the long-term care tied to these conditions takes place outside hospitals — through paid support at home or in assisted living and skilled nursing facilities — where costs can reach tens of thousands of dollars a month and are wholly paid out of pocket. Gaps in insurance coverage further expose households to high medical costs, adding to the financial and caregiving burden increasingly falling on individuals and families.
Two new nationally representative studies, co-authored by Sandro Galea, MD, DrPH, examine these pressures from different angles. One explores the scale and reach of caregiving across the U.S. adult population. The other examines how medical debt increases the risk of housing instability. Together, the findings reinforce growing evidence that financial strain is not peripheral to health outcomes, but central to shaping them.
Galea is the inaugural Margaret C. Ryan Dean of the Washington University in St. Louis School of Public Health, the Eugene S. and Constance Kahn Distinguished Professor in Public Health and the university’s vice provost for interdisciplinary initiatives. He also serves as editor in chief of JAMA Health Forum.
A shared national experience
Nearly six in 10 U.S. adults — more than 155 million people — expect to take on caregiving responsibilities for a family member or friend in the future, according to a study published in Health Affairs Scholar. One in four adults reported providing care within the past year, and one in five said they are currently caregiving.
Using nationally representative data from 2,020 adults collected in spring 2025, the study examined past, current and expected future caregiving across age, gender, socioeconomic status, place of residence and political leaning.
Caregiving touches a broad, bipartisan share of the population, the study found, underscoring the urgency of national planning and stronger systems to support family caregivers in an aging nation. “Caregiving is the hidden backbone of U.S. health,” Galea said. “It is how long-term care actually is delivered in this country, and it touches people across backgrounds, beliefs and stages of life.”
Adults with prior or current caregiving experience were far more likely to expect to provide care again, a pattern the authors describe as “serial caregiving” — repeated caregiving over the life course as family members age or needs change. Younger adults also were more likely to expect future caregiving, anticipating care for aging parents or other loved ones. While women historically have shouldered most caregiving responsibilities, the gender gap has narrowed, with men now making up about 40% of caregivers.
Because unpaid family caregivers serve as the de facto care delivery system, the sustainability of that system has direct implications for population health.
The findings come amid widespread gaps in long-term care planning nationwide. Previous research shows that nearly half of older adults underestimate long-term care needs, and 62% mistakenly believe Medicare will cover nursing home care.
At the same time, expected average long-term care expenditures per person are nearly six times the average annual Social Security benefit, making advance financial planning critical. Family caregivers also incur substantial out-of-pocket expenses and face growing financial risk the longer they provide care. Despite these realities, most adults who expect to become caregivers report having taken few steps to prepare, financially or otherwise.
Uptake of private long-term care insurance remains low, and Medicaid — the primary public payer for long-term care — faces ongoing fiscal and policy pressures. These dynamics suggest a future in which more adults will need to finance care themselves and rely more heavily on friends and family for support.
The authors argue that the scale of caregiving today, and the number of adults who expect to assume these roles, must inform policies that support caregivers financially and structurally.
Evidence from federal-state awareness campaigns on long-term care planning, including the Own Your Future campaign, suggests such efforts can be a cost-effective way to prompt planning behaviors. Renewed national awareness efforts could help older adults and their families better prepare for the financial realities of long-term care.
The analysis drew on data from the Cumulative Life Stressors Impact on Mental Health and Well-Being (CLIMB) Study conducted through an AmeriSpeak panel in 2025. The study was co-authored by senior author Catherine K. Ettman, Katherine E. M. Miller and Jennifer L. Wolff of the Johns Hopkins Bloomberg School of Public Health and Brian C. Castrucci of the de Beaumont Foundation.
Medical debt and housing instability
A second study, published in JAMA Network Open, examines how medical debt affects housing stability.
Using data from the same nationally representative CLIMB study, following 1,515 U.S. adults from 2023-25, the researchers found that medical debt was associated with a significantly higher risk of housing instability in the following year. After adjusting for a wide range of preexisting differences, medical debt was associated with a 5- to 9-percentage point increase in the likelihood of subsequent housing instability, including difficulty paying rent or a mortgage, eviction or foreclosure, or loss of housing.
Medical debt has become increasingly common in the United States, affecting an estimated 16% of adults in 2024. The burden reflects high health-care prices, uninsurance or underinsurance and out-of-pocket costs. While prior research has linked medical debt to delayed or forgone care, this study focuses on downstream consequences, specifically, housing stability, which is widely recognized as foundational to health.
The authors noted that medical debt can undermine housing through multiple pathways, including financial strain, damaged credit and aggressive collection actions such as wage garnishment or liens. Housing instability, in turn, is associated with poorer health outcomes, reinforcing cycles of economic hardship and health risk.
The findings emerge at a moment of significant policy change, including shifts in Medicaid eligibility and a recent court decision affecting how medical debt is treated in credit reporting. In this context, the study adds evidence to debates over how medical debt shapes economic security and health and what protections may be needed to prevent cascading harm.
“Medical care and housing are two major expenses that Americans face; together they contribute to affordability challenges that can influence health,” said senior author Ettman. “Understanding families’ overall financial assets can inform population health and health-care seeking behaviors.”
In addition to Ettman and Galea, the medical debt study was co-authored by Sabriya L. Linton, Kyle J. Moon and Elizabeth A. Stuart of the Johns Hopkins Bloomberg School of Public Health.
Taken together, the two studies show how financial pressures shape housing security, family stability and population health. As more responsibility for long-term care shifts to families, the findings underscore the need to treat financial strain as a central public health issue in the United States.
