Less Than 10% of the 80 Million Americans Turning 65 Have Any Way to Pay to Grow Old

Larry Nisenson opens with a question he’s asked thousands of times in presentations to people over 65: by a show of hands, who wants to move to a nursing home? Nobody has ever raised a hand. People want to age where they already are — their own home, or with family — for as long as they possibly can. The problem isn’t desire. It’s that almost nobody has actually prepared for what aging in place financially requires.

The scale of the gap is stark. Roughly 10,000 Americans turn 65 every day, a pace that continues through 2030, when the 65-plus population will reach roughly 80 million. Of that population, less than 10% hold a long-term care insurance policy — meaning tens of millions of people have no financial mechanism in place for exactly the kind of care need that eventually catches up with most aging adults.

In Episode 110 of InsurTechTalk, Larry and I covered why long-term care insurance sales have collapsed 90% since their 2003 peak despite a growing at-risk population, what actually distinguishes long-term care from every other insurance product a person owns, and the genuinely underappreciated correlation between untreated hearing loss and dementia.

About Larry Nisenson

Larry Nisenson is Chief Growth Officer at Assured Allies, an insurtech founded in 2017 by a physician with a healthcare consulting background and a technology entrepreneur with a prior successful exit. Assured Allies designs products and population-health interventions aimed at helping people age with a longer “disability-free life expectancy” — not necessarily living longer, but living healthier for more of the time they have, while building more affordable, consumer-friendly long-term care insurance products for the middle class.

The Three-Act Structure Missing a Fourth Act

Larry’s framing of how most Americans (and most financial advisors) think about retirement planning has a structural blind spot he considers the industry’s core failure.

The conventional arc has three stages: accumulation (working years, saving for retirement), distribution (living off savings, Social Security, and pensions in retirement), and legacy (for those who’ve saved well, planning to pass remaining wealth to the next generation). Nowhere in that standard framework — used by financial advisors, Vanguard, Fidelity, virtually the entire retirement planning industry — is there a fourth consideration: what happens if you’re not healthy enough to live independently?

Genworth’s Cost of Care study puts the average cost of long-term care need at roughly $235,000-$250,000. Larry’s pointed question: how many people can simply write that check? For the overwhelming majority, the honest answer is none.

Why Long-Term Care Insurance Sales Collapsed 90%

This is the counterintuitive core of the conversation — the need is growing, and the market has shrunk dramatically anyway.

In 2003, the peak year for the category, over 100 insurance companies sold long-term care insurance, generating more than $2 billion in annual recurring premium
Today, fewer than a dozen companies sell it, and total annual premium has fallen to roughly $160 million — a decline of over 90%
The root cause: insurers who built these products 30-40 years ago got the actuarial assumptions badly wrong — underestimating how long policyholders would live, underestimating healthcare cost inflation (which has run 10-15% annually in some periods), and overestimating profitability
The result has been steep, repeated rate increases on existing policyholders — Larry’s example: a policy that cost $200 a month has, for many holders, risen to $300-400 — driving both consumer anger and insurer retreat from the category entirely, since many of these older-generation products were never actually profitable for the carrier

Larry’s framing of the opportunity this creates: genuine product innovation — designing long-term care coverage with better-aligned incentives and more realistic pricing assumptions — is what’s required to rebuild a viable market, and it’s exactly the gap companies like Assured Allies are trying to fill.

Why “Just Advertise It” Doesn’t Work

I asked the obvious naive question: if the need is this large, why not just take out billboards telling people to buy long-term care insurance? Larry’s answer identifies a genuine behavioral barrier distinct from awareness.

Long-term care insurance requires people to confront their own morbidity — not mortality (which people avoid but at least occasionally plan around, via life insurance and wills) but the specific, harder question of how they’ll decline, not when they’ll die. His evidence: even when preventative healthcare is fully covered by Medicare at no direct cost, a large share of eligible seniors simply don’t go, because they “feel healthy” and would rather not engage with the question at all. Billboards don’t solve a behavioral avoidance problem — the barrier isn’t information, it’s willingness to think about it.

The Product Landscape: Where Long-Term Care Actually Sits

We used this as an opportunity to map out how long-term care differs from every adjacent insurance product, since the distinction is genuinely confusing to most consumers:

Life insurance — protects against loss of income if you die, covering obligations like a mortgage or dependents’ needs
Disability insurance — income replacement if you’re alive but unable to work due to injury or illness
Health insurance / Medicare — covers medical treatment to keep you healthy or treat an illness
Long-term care insurance — the only product covering activities of daily living: getting out of bed, bathing, dressing, feeding yourself, using the bathroom — none of which require a medical diagnosis, and none of which Medicare covers if you’re living at home rather than confined to a facility

Larry’s own father, 88, healthy and cognitively sharp but physically limited, relies on exactly this kind of coverage — illustrating that the need isn’t necessarily catastrophic illness, but ordinary physical decline that has no other insurance mechanism attached to it at all.

Assured Allies’ population-health approach treats healthy aging as three interconnected dimensions, not just physical fitness. Larry’s specific example, chosen because the mechanism is so counterintuitive: untreated hearing loss accounts for more than 8% of all dementia cases in the US, out of roughly 6.5 million total dementia cases.

The causal chain he described: hearing loss goes untreated, the person begins avoiding conversations out of embarrassment, social withdrawal follows, and isolation accelerates cognitive decline. The intervention required to break that chain is genuinely simple — a hearing test and a hearing aid — but most people never take that step because there’s no system actively prompting them to. This is Assured Allies’ actual thesis: small, targeted, low-friction interventions (not demanding someone “run a marathon”) can meaningfully change someone’s disability-free life expectancy.

The Hidden GDP Cost: 45 Million Unpaid Caregivers

This was the sharpest economic point in the conversation, and one that doesn’t show up in most conversations about long-term care as an insurance product.

There are an estimated 45 million unpaid family caregivers in the US
Family caregivers routinely decline career advancement — a promotion requiring relocation, for instance — because they need to remain physically present for a parent or loved one, with direct, compounding effects on their own lifetime earnings and retirement savings
The burden falls disproportionately on women and people of color, a pattern Larry describes as a long-standing structural inequity rather than a recent development
The burden also falls disproportionately on people without remote work flexibility — shift workers, hospital staff, retail employees — who cannot absorb caregiving responsibilities the way a remote knowledge worker might

Larry’s point, which genuinely reframes the category: every unpaid family caregiver represents lost economic productivity at a national scale — a real, if rarely quantified, drag on GDP, not just a private family hardship. The core mission he described for Assured Allies is designing coverage the middle class can actually afford — not necessarily covering the full $200,000+ potential cost, but even a partial benefit (his example: $100,000) that lets a family supplement rather than fully shoulder caregiving, freeing the family caregiver to work more, or simply to take a day off and recover.

The Conference Culture Gap

Earlier in the conversation, before the interview formally began, Larry and I compared notes on two very different conference cultures he’d experienced in the same week — NAILBA (the independent life brokerage conference in Florida) versus insurtech-focused events like ITC. His read: insurtech conferences center innovation as the explicit topic — how do disparate technology pieces fit together for a carrier trying to adopt several at once. NAILBA’s culture is almost entirely acquisition- and distribution-focused — finding and enabling more agents to sell, reducing friction in the sales process — with comparatively little conversation about efficiency gains through automation, AI, or machine learning across the value chain. Both are legitimate definitions of “innovation,” but they rarely appear in the same room.

Advice: You Get Nine Seconds, Not Nine Months

Asked for closing advice, Larry offered the same thing he’d told a friend on the phone the night before, whose mother had just fallen and needed emergency care: planning for parenthood gives you nine months; a caregiving crisis gives you nine seconds. His point is that most people sail through life with their own priorities intact until a single phone call — “mom fell, she’s going to the hospital” — instantly reorders everything. His advice is to seek out planning resources (he pointed to AARP and Assured Allies’ own consumer-facing educational content, noting Assured Allies doesn’t sell directly to the public) well before that call comes, not after.

Key Takeaways

Less than 10% of the roughly 80 million Americans who will be 65-plus by 2030 hold any long-term care insurance — the standard three-act retirement planning framework has no fourth act for this risk
Long-term care insurance premium sales have fallen over 90% since 2003 despite a growing at-risk population, primarily because early insurers mispriced the product and drove both carriers and consumers away through repeated rate hikes
Long-term care insurance is the only product covering non-medical activities of daily living — a genuinely distinct category from life, disability, and health insurance that most consumers don’t realize exists
Confronting long-term care needs requires confronting morbidity, not mortality — a distinct behavioral barrier that awareness campaigns alone don’t solve
Untreated hearing loss is linked to over 8% of US dementia cases via a social-isolation pathway, illustrating how small physical health interventions can meaningfully change cognitive outcomes
45 million unpaid family caregivers in the US represent a genuine, largely unquantified drag on national economic productivity, disproportionately borne by women, people of color, and workers without remote flexibility
Partial long-term care coverage — supplementing rather than fully replacing family caregiving — is a more realistic and attainable middle-class product design than attempting to fully insure the full average cost of care

Larry Nisenson, Chief Growth Officer at Assured Allies