by Amanda Longey
CEO, MAL Consulting
The demand for continuing care at home is real. But so is the gap between who wants it and who can pay for it. The organizations that design around that reality will build more durable programs than those that don't.
When I started in the CCaH industry over a decade ago a common message I often heard was this service was for the middle-class. However, coming from a working-middle class family my initial thought was that “these people are out of touch with what middle-class actually looks like." I still have those thoughts as I sit and hear people talk about it this way. I think of my parents who live on social security for the most part and the largest asset they have is their home. They don’t have $100,000 and $1,000 to spend per month on a CCaH membership, but if they did need care they have too much money to qualify for Medicaid. They would quickly spend down assets, so how can we create something that could potentially be affordable and provide them and other individuals in that same scenario needed services.
We have on one side: a massive and growing population of older adults who want to age in place and desperately need the kind of structured, coordinated care support that CCaH provides. On the other: the financial reality that most of those people cannot afford the programs currently on the market. According to our CCaH national benchmark survey most members of programs have median assets around $2 million. Certainly not your middle market.
This is not a reason to abandon the CCaH model. It is a reason to design it more thoughtfully. Organizations should understand the affordability gap and who falls inside it, who falls outside it, and what program structures can begin to bridge it. This is an important strategic question to ask before building a CCaH program. Here's what the data tells us, and what it means for design.
What CCaH Currently Costs
Current CCaH programs vary meaningfully in their fee structures, but the general range gives a useful frame.
Entrance fees across programs currently on the market range from as low as $20,000 to well over $100,000, with some programs charging considerably more depending on age at enrollment, health status, and benefit structure. Monthly fees typically run from $250 to $2,000 depending on the program tier and included services.
The comparison with traditional Continuing Care Retirement Community (CCRC) costs is enlightening. The national average CCRC entrance fee is around $480,000 sometimes topping out over $1 million, with monthly fees averaging over $4,000. By that measure, CCaH is substantially more accessible. But "more accessible than a CCRC" is not the same as "affordable to most older adults." The organizations that conflate those two things will build programs sized for a market that is much smaller than they expected.
Who Is Actually in the Addressable Market
Given the income and asset data, the realistic private-pay addressable market for CCaH is concentrated in a specific financial tier. Broadly, that means households with annual income of approximately $75,000 or more, meaningful financial assets beyond their home equity, and the financial literacy and planning orientation to make a proactive enrollment decision years before a care need arises.
In practical terms, this tends to skew toward:
- Dual-income retiree households with pension income, Social Security from two earners, and some investment portfolio
- Single-earner households with significant home equity that can be leveraged, particularly in markets where homes have appreciated substantially
- Adults 60–72 who are still in the planning mindset and have sufficient income to absorb monthly fees before intensive services are needed
- College-educated retirees who engage actively in financial planning and understand the value of locking in coverage before a health event
But this is also not the whole picture. The vast majority of older adults, including many who want exactly what CCaH offers, are priced out of programs designed solely for the top income tier. And that has implications not just for equity and mission, but for program viability.
The Middle-Income Problem Is a Program Design Problem
Here is the uncomfortable truth that CCaH organizations need to reckon with: the middle-income older adult who has a paid-off home, modest savings, and a genuine desire to plan ahead remains largely unserved by current CCaH program structures.
This person cannot comfortably absorb a $75,000 entrance fee. They may stretch to participate in a lower-cost program. Their ability to pay monthly fees through a lifetime may become difficult if healthcare costs increase substantially or other living expenses continue to rise at higher rate than increases to social security. The demand is present. The desire to age in place does not correlate neatly with income. Middle-income older adults want the security and care coordination that CCaH provides at least as urgently as their wealthier counterparts. They simply can't access it through the existing fee structures.
Organizations that solve that design problem of finding ways to deliver the core CCaH value proposition at a price point accessible to the middle-income tier could potentially unlock a dramatically larger addressable market and build programs with far greater long-term impact.
What Program Design Implications Follow
Reckoning honestly with the affordability gap leads to several specific program design considerations:
Tiered benefit structures. Not every member needs the same benefit package on day one. Different tiers can offer price flexibility.
Entrance fee flexibility. Some programs have experimented with lower entrance fees paired with slightly higher monthly fees. Others have explored installment structures for entrance fees. This helps reduce the upfront barrier to entry of the program.
Home equity as an asset. For middle-income older adults, the most significant financial asset is often their home. Programs that help prospective members think through how home equity could fund enrollment have a larger addressable market than those that assume liquid financial assets only.
Actuarial discipline is non-negotiable. Every accommodation made for affordability must be tested against actuarial sustainability. A program that enrolls middle-income members at a price point that can't support its long-term care obligations is going down a slippery slope. The goal is not to make CCaH cheap. It is to make it as accessible as possible while remaining financially sound. Those two goals can coexist with careful design, but they require discipline to balance.
What to Do With This Information
For organizations in early-stage CCaH exploration, the affordability analysis belongs in the feasibility work, not as a reason to walk away, but as a design parameter. Key questions to work through:
- What is the income and asset distribution of the 65+ population in your primary service area?
- At what price point does your program become accessible to the top 20% of that population? The top 30%? The top 40%?
- What benefit structure could serve the middle-income tier sustainably and what would that require actuarially?
- How does your organization's existing brand and community trust translate into enrollment likelihood across income tiers?
- What financial counseling or planning support could you provide to help prospective members understand their options?
There are no universal answers. But the organizations should consider these questions as they are building a program. Those who can develop options that are more widely affordable will build CCaH programs that are both financially sustainable and genuinely impactful.
Interested in understanding the affordability landscape in your specific market and what it means for CCaH program design? Book a consultation to learn more about market feasibility analysis and program development. Also check out our Resources page for more information.