Rethinking who delivers care — and where and how.

The American healthcare delivery system faces known challenges: it’s costly and outcomes lag behind peer nations. And the system is about to be tested harder. One-third of practicing physicians are within a decade of retirement age, and the country is on pace for a shortage of up to 86,000 physicians by 2036 — precisely as the population of older adults that require more care is rapidly increasing. Closing that gap requires rethinking who delivers care, where it happens, and how the practice should evolve.

The physician shortage has two underused levers: role definition and immigration. Nurse practitioners and pharmacists aren’t just gap-fillers — allowing them to work at the top of their scope of practice expands access to basic care. It is also worth noting that America’s healthcare workforce is substantially immigrant: Any serious conversation about the healthcare labor shortage is inherently an immigration policy conversation.

Redesigning how and where care happens to meet the needs of a larger, older, and more medically complex population is already working in pockets. Age-friendly care standards consider context by asking what matters most to an older patient. Investments in agentic AI are expanding capacity. Where care happens is shifting too — successful hospital-at-home initiatives have opened the door to a broader range of healthcare delivered outside its walls, from telehealth to palliative care.

The agenda

Expand workforce capacity. The legacy fight over Nurse Practitioners’ and Physician Assistants’ scopes — what they can diagnose, what they can prescribe — is shifting: 30 states and D.C., up from 22 in 2020, now grant nurse practitioners full practice authority, and a smaller group of states have done the same for physician assistants. Pairing this with local, fast, and purpose-built pipelines for auxiliary healthcare roles benefits both our health and economic mobility.

Nearly one in five U.S. healthcare workers are foreign born — including 41% of home health aides, 28% of personal care aides, and 26% of physicians and surgeons — yet the country has no visa category reserved for healthcare workers at all. A $100,000 H-1B fee was vacated by a federal judge before it could take effect — but H.R. 7961, a bipartisan bill introduced in March 2026 to exempt healthcare workers from that fee permanently, is exactly the kind of proactive, common-sense strategy our healthcare system needs. Passing it into law is the floor, not the ceiling: A path to citizenship for individuals who commit to healthcare training to address our shortage would both increase talent supply while fostering legal status and economic mobility.

Make the science of aging table stakes for medical education. Gerontology is the broader science of aging — the biological and functional processes of decline — studied across biology, public health, and social science. Geriatrics is the medical specialty that treats disease in patients over 65. Today, the science of aging mostly reaches physicians through that one specialty. But aging isn’t a specialty problem: With U.S. life expectancy at 79, aging accelerates sharply around age 50, and cancer, neurodegenerative disease, and cardiovascular disease each take roughly 20 years to incubate before symptoms appear — meaning all physicians, not just geriatricians, are already treating patients partway through that process, whether or not they’re trained to recognize it.

The population math makes this urgent: Americans over 40 will soon outnumber those under 40, and that will stay true through 2100 unless immigration policy changes. Every primary care doctor, cardiologist, and oncologist needs a working knowledge of the science of aging, not just the geriatricians who see patients after 65. Advances in gerontology should be incorporated into medical school curricula and board requirements across every specialty. We can build on what already exists — the Age-Friendly Health Systems initiative, active in more than 6,900 sites — by extending that same model into training the next generation of physicians who will care for a majority-older society.

Make healthcare at home a priority — and fund it like one. Care moved into hospitals over the 20th century for practical reasons: sanitation, professionalization of medicine, and the economies of scale from concentrating staff and equipment in one building. That logic is reversing. Hospital-at-home can improve outcomes and cost — a 2026 study of nearly 16,000 Medicare patients found significantly lower rates of in-hospital death and ICU escalation than traditional inpatient care. — and it’s pulled forward as much by patient preference as by capacity pressure: a larger, older population that would simply rather recover at home, aided by monitoring technology that didn’t exist a decade ago.

“Healthcare at home” includes at least four systems wearing one label, each needing its own set of strategies, policies, and investments. Acute hospital-at-home has a funding runway to 2030 pending in Congress; we could make it permanent, and fund the upfront cost of building a program the way a construction loan funds a hospital wing, not through reimbursement alone. Palliative care also has the evidence base to fund it as core infrastructure for cost avoidance.

Lean into the AI moment to fix healthcare’s foundation. AI has three jobs for a majority-older society, and the order matters. The first is augmentation: creating capacity for a workforce that isn’t growing fast enough for the population it now serves. Hospitals are already living this — a shrinking working-age population supporting a larger population of older adults — which is why AI here is valued as return on employee over a return on investment. Ambient AI scribes have been shown to meaningfully reduce clinician burnout within just weeks of use, and investments in virtual-nursing deployments aim to handle admissions and monitoring so bedside staff can focus on patients.

The second job is clinical practice itself. Incorporating AI into medical practice will require not just evidence-based innovations, but a shift in behavior. Despite clinical evidence that AI-assisted mammography outperforms humans alone, it is not yet  standard of care. An increase in the volume of older patients will inevitably result in the increase of diagnostic tests for cardio, metabolic, neurological, and muscular-skeletal disorders — all of which require innovation and consensus to effect change.

The third, and most important AI opportunity, is to use this moment to address the hurdles that drive high cost and poor outcomes: interoperability challenges, opaque pricing, and reimbursement that rewards volume over outcome. Automating what doesn’t work only compounds the dysfunction; we need to invest in foundational system change and build governance now, while adoption is still nascent enough to set the norm.