In the U.S., millions of families face an increasingly common challenge: how to care for elderly relatives at home while simultaneously managing work, raising children, or other commitments. This has a disproportionate impact on women, who often choose to provide personal and family support to aging loved ones, sometimes while also navigating the demands of a professional career. At the same time, the vast majority of older Americans express a desire to age in place, preferring the comfort and dignity of home over institutional care. As demand for home-based support grows, a closer look at the regulatory and policy landscape reveals how current rules often hinder, rather than help, families trying to meet these needs.
Aging in place is not just a sentimental preference—it’s a deeply practical and emotional one. Many older adults do not require intensive medical intervention or constant supervision. Instead, they often need minor assistance with daily tasks such as meal preparation, transportation, and scheduling. These supports are often what make the difference between being able to remain at home and entering a facility Yet the significant cost of in-home companionship, averaging around $80,000 per year for full-time live-in help (and even more in certain regions), makes this option unaffordable for most. Compounding this challenge, Medicare generally does not cover “non-medical personal services,” leaving many families scrambling to find feasible options.
A major factor behind these affordability and access challenges is the regulatory framework governing in-home support. The issue arose in 2013, when the U.S. Department of Labor reinterpreted the “companionship exemption” under the Fair Labor Standards Act. Previously, live-in companions and those hired through home care or staffing agencies were exempt from rigid overtime and wage provisions. The 2013 Home Care Rule narrowed this exemption, stipulating that companions could not dedicate more than 20% of their time to direct support tasks such as meal preparation or dressing if they were to remain exempt. This shift brought additional costs to families and introduced new compliance burdens. In response, some families have resorted to informal, “off-the-books” arrangements, which carry potential risks and drawbacks for everyone involved.
In response to the growing challenges posed by this regulatory structure, the Department of Labor has proposed rescinding the 2013 Home Care Rule and returning to the previous interpretation of the companionship exemption. Such a revision would make it easier for families to legally and affordably bring in live-in support. By restoring flexibility and reducing administrative burdens, this proposal would improve access to in-home support while preserving and strengthening safeguards for companions. Crucially, it addresses the needs of a large and growing group of seniors who are not confined to a bed or dependent on intensive medical care, but who still need companionship to maintain their quality of life. Americans need the freedom to craft arrangements that fit their unique circumstances—whether that means live-in companions, part-time assistance, or another form of support—without being forced into a rigid, government-defined model.
A useful point of comparison can be found in the au pair program, a long-running, State Department-overseen cultural exchange initiative that allows foreign nationals to live with American families in exchange for providing childcare. Notably, the program’s structure is intentionally light on regulation, yet it incorporates crucial safeguards. Au pairs receive room, board, a stipend, and educational support, while host families gain access to live-in help that is both flexible and cost-effective. Importantly, the relationship is designed to be mutually beneficial. The very term “au pair,” means “on par,” reflecting the spirit of equality and shared experience. Beyond practical help, the framework fosters meaningful relationships, cultural exchange, and genuine companionship.
Policy proposals from the Biden administration aimed at overhauling the au pair program have illustrated the delicate balance between protection and overregulation. These proposed changes, such as significant increases in mandated compensation, threatened to make participation financially untenable for many families. In some states, these proposed regulatory shifts quickly led to dramatic declines in au pair placements. Complaints about these potential new rules were met not only from host families who would have been priced out of the market, but from au pairs who knew that the additional red tape would have changed the relationship and made opportunities for work more scarce.
The parallels are striking: had the proposed regulatory changes to the au pair program gone into effect, the structure of this flexible model would likely resemble the restricted in-home support space we see today—largely a result of the 2013 Home Care Rule and its impact on accessibility and affordability.
This underscores a broader truth: poorly calibrated regulations, even if well-intentioned, can disrupt systems that are working well for both those providing and receiving support.
Drawing on the success of the au pair program, policy leaders have proposed expanding this model to provide elder support. The core components—live-in companionship, shared experience, and structured yet flexible arrangements—translate well to the needs of older adults who benefit from consistent, human-centric assistance. This model could be implemented without burdening taxpayers and would rely on a supportive legal framework that empowers families while protecting individuals from abuse or exploitation.
The potential benefits of such an approach are especially significant for women, who make up the majority of both informal and professional support providers. By increasing access to flexible, affordable in-home assistance, more women could remain in the workforce or support loved ones while maintaining other responsibilities while still building financial security. In the longer term, as these same women age, they would also benefit from a system designed to prioritize autonomy, companionship, and dignity. Society as a whole stands to gain when support structures are grounded in meaningful relationships, rather than bureaucratic definitions or inflexible standards.
The ongoing conversation about in-home support raises important questions about how we define companionship, its provision, and whom our policies are truly serving. The contrast between overregulated systems and those that strike a careful balance offers lessons for lawmakers, advocates, and families alike. As the population ages and daily living needs become more complex, there is a growing opportunity to rethink and reimagine our systems in ways that promote dignity, sustainability, and human connection. One-size-fits-all policy approaches are rarely effective, especially in caregiving. What older Americans need is choice: the ability to tailor care arrangements that work best for them and their companions, in ways that reflect real relationships, preferences, and life circumstances.