11 Fixable Things that Make Life Harder for the Elderly, the Sick, and the Poor
Making it cheaper to be old, sick, or fragile in America. An abundance playbook.
No one plans to become fragile. You get in a car crash and can’t walk. A virus leaves your brain foggy. You start getting seizures and can’t drive. You turn 75 and the stairs become difficult.
Some of the rules we’ve built have made it harder for people to seek care and live independently. Here are some things we could change, most of which require no new spending.
I plan to keep updating this list.
1. Make it legal to rent out a lockable bedroom in a shared building
This is illegal in most cities.
Single Room Occupancy hotels, which are a private bedroom and shared bathrooms, housed millions of low-income Americans for most of the 20th century. In 1950, SRO units were 10% of all rental units in some major cities.
Elderly people were as much as half of SRO tenants. However, most cities outlawed them in the 1980s. This made the lives of the elderly and poor more precarious. Pew notes this increased homelessness:
As the nation’s least expensive source of housing disappeared, homelessness soared in major cities across the United States. In New York City, for example, the number of homeless residents increased from a barely visible population to almost 30,000 by 1987. About half of men entering homeless shelters in the city in 1980 reported they had previously lived in SROs.
Seniors are the fastest growing group experiencing homeless.
2. Let families build a room on their own property for a struggling loved one
In much of Japan, you can build things on your lot like a studio or sleeping quarters for a relative. Most of America is zoned single-family only. You usually can’t add a backyard room for an aging parent.
Backyard units used to be how people with less money lived near family. It also was a source of modest passive income for the families who built them.
Accessory Dwelling Units (ADUs) are an attempt to bring these back, but most jurisdictions make them difficult to build. For example, with “temporary use” permits that expire when the senior dies, “removability” requirements that conflict with building codes demanding permanent foundations, sunsetting clauses that make them bad investments.
3. Treat manufactured homes the same as any other home in zoning law
A manufactured home or a “mobile home” costs roughly half what a site-built home does. People over 60 are a third of adults living in them. It’s one of America’s largest sources of affordable senior housing.
Many jurisdictions ban them outright, require large minimum lot sizes, prohibit replacing a unit when someone moves out, or segregate communities far from doctors, transit, and groceries. Vermont and Maine effectively legalized these homes: no zoning regulation can exclude manufactured homes except on the same terms as conventional housing.
4. Let small groups of people share a home and a caregiver
Four to six seniors sharing a house and a caregiver is effectively illegal. Three barriers stop it. Many zoning codes cap unrelated persons at four. Medicaid allocates aide hours per individual with no way to pool them, even though one aide under one roof is more efficient than four aides visiting four homes. And the moment seniors share a caregiver, many states classify it as an assisted living facility requiring fire codes, staffing ratios, commercial inspections designed for a 100-bed building.
These regulations and licensing requirements work well for protecting people in institutions. However, requiring commercial kitchen inspections for a house with four seniors and a caregiver stops people from forming tiny community-centered solutions.
The fix: create a regulatory category between “person alone at home” and “licensed facility” e.g. a small shared care home with proportionate safety rules.
5. Stop requiring government permission to add nursing home beds
NIMBY blocks some nursing homes, but another barrier is that 34 states require a Certificate of Need just to add nursing home beds. You need state approval to build supply. Sixteen states go further with outright construction moratoria.
These laws were designed to prevent overbuilding and control Medicaid costs. In practice, they protect existing facilities from competition and keep supply artificially low. Repealing CON for nursing homes and classifying small care homes as a permitted residential use by right would expand options.
6. Remove the legal ambiguity around homesharing
Homesharing matches older homeowners — property-rich, cash-poor, often isolated — with people who need a room to live in and are willing to help in the home for some hours. More than half of participants over 50 feel safer, happier, and less lonely.
It would happen on its own if the legal framework were clear. But running a matching service at scale can trigger commercial-use zoning violations. Advertising a spare room raises questions about whether your home is now a rooming house. States should explicitly classify renting a room to a matched housemate as a residential use.
7. Make it clearly legal to open your home to someone else who needs meals and daily help
Right now, if you wanted to open a spare bedroom to an elderly neighbor who needs meals, company, and help with daily tasks (but not medical care) you probably couldn’t tell whether that’s legal due to liability, facility classification, residential home use, and Medicaid reimbursement.
Pennsylvania is helping get this service off the ground: the state runs a program where ordinary people host up to three adults who need daily assistance. The host gets paid. The guest lives in a home, not an institution.
This often doesn't require a new program. It requires states to clarify the arrangement is legal.
8. If states raise the minimum wage, they need to raise Medicaid home care rates too
Home health aides are projected to be the largest occupation in the U.S. economy by 2032. Fourteen million Americans depend on them to stay out of institutions. In every state, their median wages trail retail and customer service by $3.73 an hour, with 75–80% annual turnover.
The reason is structural: Medicaid pays for nearly two-thirds of all home care spending, which means most aides’ wages are set by state reimbursement rates, not the labor market. When a state raises its minimum wage, every private employer adjusts automatically. Medicaid-funded agencies can’t unless legislators separately vote to increase reimbursement rates.
The result: every minimum wage increase makes home aide work relatively worse compared to every other low-wage job. Hence, a shortage.
9. Let home aides work in any state without re-licensing
Some states require more than double the 75-hour federal minimum for training. These extra requirements fragment what should be a national labor market. A single federal standard would make workers’ lives easier, and allow them to move to where the need is.
10. Create a visa for caregivers
38 percent of home health aides are foreign-born and may be at risk from changes in their legal status. There is no temporary working visa for them. Temporary visas for nurses, authorized in 1989 and 1994, both expired and were never renewed.
11. To address the nursing shortage, let hospitals train nurses again
80,000 qualified applicants were turned away from nursing programs in 2024 because of lack of instructors. The wage gap between faculty roles and clinical roles is $18,000–$27,000. Letting hospitals run training programs again would help. West Virginia University Medicine has a hospital-based nursing diploma program for high school graduates.
In the 1980s, professional associations pushed nursing toward four-year university degrees, shifting training away from hospitals into universities and colleges with government-capped budgets.
Some of these rules persist through inertia. Others are actively defended by the operators, associations, and property owners who benefit from them. The people harmed are scattered and often don’t know what they’re missing.
None of this replaces stronger social supports: better cash transfers, expanded Medicaid, a long-term care benefit.
These aren’t in competition. You need both.
It's actually crazy how many of these I didn't even realize were "illegal". My wife and I have violated at least two of these just by helping random people in our life. Let the people bring abundance!
It seems like half the items here are housing regulations that heavily assume nuclear-family-only homes and the other half are regulations that distort supply and demand of caregiving. Is that a fair characterization?
If that's fair on the first point, I'm curious about where the state of that nuclear-family assumption is right now - i.e., is it still as strong in the culture as when these regulations were created? If it's still strong, how much of a barrier will it be to enacting reforms that enable more flexibility and more affordable options for seniors?