United States

The United States is, for much of the world, the cautionary baseline: extraordinary private innovation sitting on top of an extraordinarily thin public safety net for long-term care. Understanding the US is mostly about understanding that gap.

Start with who actually does the caregiving. An estimated 38 million Americans provided unpaid care to an adult in 2021 — roughly $600 billion worth of work, a figure AARP's 2026 update puts closer to 59 million caregivers and $1 trillion (AARP). That unpaid labor isn't a supplement to the US system. It is the system. When families can't cover the gap, the paid workforce meant to step in is stretched thin: home-care aides earn a median of about $17 an hour, roughly a third live in or near poverty, and the country is on track to be short around a million of these workers by the early 2030s (PHI).

The financing is where the US diverges hardest from its peers. There is no national long-term-care insurance. Medicare — which most Americans assume will cover this — does not pay for long-term custodial care; it covers only short, skilled stints after a hospitalization. So the default payer becomes Medicaid, but only after a person has spent down their savings to near-poverty, with nursing-home care running roughly $10,000 a month. The one serious federal attempt at LTC insurance, the CLASS Act, was judged actuarially unworkable and repealed in 2013 (Commonwealth Fund).

What fills the vacuum is a patchwork. Medicaid home-and-community-based waivers let some people get care at home instead of an institution, but they're means-tested, vary widely by state, and often have waitlists. The Older Americans Act funds Area Agencies on Aging as a local front door, but they're perpetually under-resourced. Washington's WA Cares Fund — the nation's first public long-term-care social-insurance program, with benefits opening in 2026 — is the first domestic proof that another way is possible, but it's one state (WA Cares Fund).

Where the US genuinely leads is technology. New York State's deployment of the ElliQ AI companion — more than 800 units sent to isolated older adults, with the state reporting a roughly 95% drop in self-reported loneliness — is one of the most ambitious public AI-companion programs anywhere (NY State Office for the Aging). Around it sits the world's deepest aging-tech startup scene and a mature market for fall-detection pendants, medication dispensers, and remote monitoring. Physical care robots are further behind — mostly pilots, not homes at scale.

The honest takeaway: the US has the gadgets and the innovation, but not the financing or the coordination. A family can assemble an impressive shelf of caregiving technology and still face the central American caregiving reality — that the months and years of hands-on help are theirs to pay for, in money or in their own time, until the money runs out. The global lens doesn't expose a technology gap. It exposes a missing promise.