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The Netherlands makes aging and long-term care a priority. In the US, it’s a different story.

The Dutch offer hard-won lessons for a “fragmented” US system.

Community of care: Residents and neighbors of the Mariaoord nursing home in Dongen played a board game during adult day care in a pilot program that combines nursing care with aging in place.Ramon van Flymen for The Boston Globe

THE HAGUE — A demographic tidal wave looms. By 2040, one in four Dutch residents will be over 65. The same “silver tsunami” is building in much of the developed world, including the United States. And it will strain the budgets and test the ingenuity of nations.

Here in the Netherlands, a social welfare state roughly twice the size of Massachusetts, leaders have been planning for this graying of society for a half century. Drawing on public funds, a sense of shared responsibility, and compulsory insurance premiums paid throughout their working lives, those born in the post-World War II baby boom take for granted that they’ll have the home and nursing care they need as they age.


“It’s pretty much undebated,” said Bram Wouterse, assistant professor in health economics at Erasmus University in Rotterdam. “People know that when you get old, the government will provide good care.”

Pensioners Bert and Thea van den Heedcamp sat outside their home at Polder Hofje, a four-year-old independent living complex in Anna Paulowna, near the North Sea. Ramon van Flymen for The Boston Globe

In the United States, it’s a far different story. The question of who will take care of older Americans, and who will foot the bill, keep many awake at night. A scathing report in April from the National Academies of Sciences described the US long-term care system as “ineffective, inefficient, [and] fragmented.” The wealthiest can afford quality care; those with less money must navigate a Byzantine system that forces them to spend down their savings to get a nursing home bed.

And despite that increasingly glaring gap, there is little chance this picture will change any time soon. The cost would be vast. Older Americans are projected to account for more than 20 percent of the US population within two decades, but addressing their needs in a sweeping fashion would require a political will that is not yet visible.

Still, the example set by the Netherlands is intriguing — and chastening.


A visit to this nation of 17 million, jutting into the North Sea, offers a look at a society grappling seriously with the struggles and costs of aging. Like their American counterparts, the Dutch face not only a rapidly growing older population but also a worsening shortage of elder care workers. Those trends are fueling anxieties on both sides of the Atlantic. But in the Netherlands, there’s an age-friendly game plan, bolstered by a broad consensus that older people deserve to get the care they need, and that they shouldn’t feel isolated or warehoused.

The Dutch use the word solidariteit, or solidarity, to describe their commitment to older residents. The Netherlands was the first country in Europe to introduce a mandatory long-term care system in 1968. It has updated and refined its plan several times since, holding to its vision of universal care even as it relies more on managed competition between nonprofit providers and insurers to control costs. The most recent overhaul, in 2015, aims to help residents age in place.

People want to stay at home, said Theo van Uum, director of long-term care at the Dutch Ministry of Health, Welfare, and Sport in The Hague. That new emphasis also anticipates and seeks to ease the growing weight of nursing home care on the national coffers.

A tour of senior sites in the Netherlands, from diverse cities dating back to the 12th century to rural hamlets surrounded by tulip fields, reveals some surprises. The Dutch approach looks nothing like a rigid nationalized system; it’s varied, experimental, and humane.


Its much-imitated De Hogeweyk in Weesp, a town on the outskirts of Amsterdam, seeks to “de-medicalize” dementia care in a miniature Dutch village, complete with grocery store, tavern, and barbershop, where residents roam with minimal supervision. Nursing homes have been reimagined in the last decade; instead of hospital-style facilities, many now look more like De Voorhoeve, a nursing home in Utrecht built around smaller human-scale wings, or kleinschaliges, with single rooms to create both a sense of autonomy and community.

The cost of the Dutch system is enormous. The Netherlands spends over 4 percent of its gross domestic product on long-term care, more than any other advanced country, according to the Organization for Economic Cooperation and Development. The equivalent expenditure in the US would top $800 billion per year, more than what is now spent on Medicare, which doesn’t cover long-term care. Mandatory payroll deductions for elder care, including contributions from employers, amount to as much as 9.6 percent of income for Dutch workers.

By contrast, the US spends about 1.5 percent of its GDP on late-in-life care — less than any Western European country, Canada, or Japan — and has no national insurance program. Fewer than 7 percent of Americans over 50 have private insurance for long-term care.

But data suggest that big spending pays dividends in happier, healthier, and longer lives. Life expectancy averages 82.2 years in the Netherlands, compared to an average of 78.8 in the US, according to the OECD. Multiple factors play into life spans, but the gap is meaningful.


An international survey of older adults by the Commonwealth Fund last year found 68 percent of Americans over 65 reported having two or more chronic health conditions, compared to 40 percent of their Dutch counterparts. And only 2 percent of Dutch respondents said they were stressed about having enough money to pay for their food, rent, or bills, versus 11 percent of older Americans, the findings showed.

In a separate 2021 survey on loneliness, which casts a discomforting shadow over tens of millions of older folks worldwide, the database firm Statista found that only 15 percent of Dutch adults acknowledged feeling lonely, less than half the share of Americans (31 percent).

Some of the same innovations and approaches to aging seen in the Netherlands can be found in the US, but only a sliver of the population can afford them. And US planning for a wider safety net has stalled. The new Inflation Reduction Act, while lowering the cost of drugs for older Americans, doesn’t include billions proposed for home-based care in earlier versions of the bill. A federal long-term care insurance plan was struck from the Obamacare health reform bill in 2010. Since then, Washington state has launched its own insurance program, and other states are debating whether to follow. Massachusetts is not among them.

Some are asking how long the Netherlands can continue its generous spending on its oldest residents amid emerging financial strains and an over-65 population projected to swell by 53 percent over the next two decades. “I wouldn’t expect it to be the same when I get older,” said Marlies Bar, a PhD candidate at Erasmus, sharing a view common among younger people here. “It seems unsustainable.”


And yet, as the demographic tidal wave approaches, few in this low-lying country — celebrated for holding back the sea, using dykes to prevent farm land from flooding — are prepared to cede what they’ve built.

Nursing homes where old folks ‘matter to us’

De Voorhoeve, in the canal-lined city of Utrecht, looks like a cross between a college dorm and a senior center. But it’s an apt model of how the Netherlands is refashioning nursing home care with creativity, flexibility, and help from an army of everyday people.

When it was built 20 years ago, De Voorhoeve shoehorned five or more residents into one bedroom. Six years ago, it was made over into a dozen small-scale kleinschaliges, clusters of four or five single rooms with common areas where residents dine and socialize together.

Unlike in the US, where most nursing homes are operated for profit, almost all in the Netherlands are nonprofit institutions. Residents who paid into the system earlier in life are admitted based on their health indications, not bank balances. They live rent-free but, depending on their financial means, can be required to make small contributions. This kind of egalitarian system prevents the class stratification seen in American nursing homes, which attract people of similar income levels.

Janni Van Dijk, 89, who was alone at home after her husband died, moved into De Voorhoeve last year; her fellow residents include retired teachers, carpenters, bus drivers, and doctors. Van Dijk, who uses a walker, sits in the garden with neighbors on sunny afternoons. In her modest room, she displays photos of her late husband and daughters. “The nurses are my family, too,” she said. “They’re good to me.”

The home also draws about 80 volunteers, some from the surrounding neighborhood, who help to offset the staffing shortage. That’s typical in a country where care for the elderly is a community undertaking. Nursing homes here rely on a workforce of about 400,000 employees aided by roughly 200,000 volunteers, including relatives and neighbors.

“There’s a broad sense that we help with long-term care residents because they matter to us,” said Michiel Kooijman, policy adviser at Actiz, a nursing home association based in Utrecht.

The terrace and grounds at De Voorhoeve have the feel of a community garden, with apple trees and pots of herbs and flowers. Neighborhood residents drop by for a sandwich and to chat with residents, and students from a nearby elementary school help elders with jigsaw puzzles. Activities include Dutch bowling with small pins, and a game called blikwerpen, in which residents toss foam balls into tin cans.

Spouses and adult children not only visit loved ones at nursing homes but plant flowers or lead activities there. Kooijman’s sister-in-law, for example, helped out at a rural nursing home where her mother lived. After her mother’s death, she continued to volunteer at the home and, when she married, some of its residents took part in the ceremony.

Local institutions haven’t forgotten the nursing homes, either. The art museum of Utrecht brings paintings and sculpture to De Voorhoeve for residents to admire. “They don’t go to the museum,” said the home’s activities director Nick Werne, “so the museum comes here.”

The centrality of community life for the Dutch has also produced an innovative approach to the hardest kind of care to deliver: the dementia village known as De Hogeweyk, located in the historic shipping town of Weesp.

Once it was a four-story concrete structure where movements were restricted, but a massive demolition and renovation has yielded a walkable village of 27 homes, each with six residents, laid out in two-story buildings along the gated perimeter. More houses are being added this year.

On a bright spring afternoon, residents strolled de passage, an outdoor corridor festooned in orange bunting for the King’s Day celebration, held on King Willem-Alexander’s birthday. They passed a café and club room for baking and painting by Rembrandt-inspired village residents. Inside a grocery shop, once used as a storage site, a cashier trained in dementia care chatted with residents and care workers around shelves stocked with zucchini, tomatoes, meats, cheese, bread, and wine.

Nearby, on a street lined with linden trees and bluebells sprouting from raised beds, residents sat on chairs, their walkers stationed nearby, chatting about grandchildren, soccer, and what was for dinner. Staffers, some from former Dutch colonies like Indonesia and Suriname, kept watch.

Residents can’t leave the village, but are given more freedom — and accept more risk — than at other memory care homes. “It’s about being outdoors and taking a walk,” said founder Jannette Spiering. “People with dementia want to stay part of normal life, to mingle.”

Spiering said the concept arose in the 1990s, when complaints of isolation and stigmatization arose in the old facility. “I looked at what we offered,” she recalled. “And I said: ‘That’s not what I’d want if I lived here.‘ So we did a profound rethink.” It led to a new sense of identity — not as a traditional nursing home, but as “a community of people living with dementia.”

De Hogeweyk has become an international example of what’s possible in memory care. It’s drawn more than 200 visiting delegations from around the world, from Norway to New Zealand, and many of them have taken its ideas and philosophy back to their own countries.

“We see a movement around the world,” said Spiering, who consults with homes globally. “It’s the re-humanizing of nursing home care.”

The Dutch are intensely interested in finding ways to connect nursing homes with older folks living nearby, so moving to more intensive treatment doesn’t come as a shock. They also work hard to keep people at home as long as possible, with help from local governments.

A nurse walked with a resident in the courtyard outside Mariaoord in the southern city of Dongen. The nursing home is in a 140-year-old monastery next to a chapel surrounded by new apartments. Ramon van Flymen for The Boston Globe

That’s the focus at Mariaoord, a nursing home nestled in a 140-year-old brick monastery with high ceilings and stained glass windows in the southern village of Dongen. It was started by Catholic nuns from the Order of St. Francis of Assisi, who came from Belgium in the early 1800s. More than a dozen sisters still live there, but the home, like many once operated by religious groups or labor guilds, is now run by a nonprofit.

The Mariaoord program aims to rekindle a “we’re-in-this-together” spirit that’s eroded in modern times, said director Albert Vlemmix. “The story is 800 years old,” he said. “St. Francis called it love. We call it care.”

Seniors who live independently in Dongen get support from village officials, including visits from social workers called “life coaches.” And they’re regular guests at Mariaoord, which abuts the senior apartments. There they join in activities with the nursing home residents, sometimes belting out hymns with the retired nuns who call the monastery home.

Lucie Schilders, a retired office worker who sings in a choir and is part of the Mariaoord community, talked with two nursing coaches at her apartment outside the monastery in Dongen. Ramon van Flymen for The Boston Globe

Vlemmix expects the model to be adopted widely in coming years when tighter criteria will require more serious health indications for admission to nursing homes in the Netherlands. The government wants to double nursing home capacity over the next two decades to reduce waiting lists, but the new criteria will reserve most of the beds for those with disabilities or serious illnesses like Alzheimer’s or Parkinson’s.

The program at Mariaoord seeks to keep older people at home for years, even after they’re diagnosed with dementia or other illness, through a strategy dubbed “re-ablement.” It includes home modifications, such as installing safety bars in bathrooms, but also convening “kitchen table talks” with families and neighbors to set up networks and routines for daily living activities like walking, dressing, and bathing.

“We have to rebuild that society so people can’t say, ‘It’s not my problem,’” Vlemmix said. “The elderly need trust and safety.”

Lucie Schilders, an 83-year-old widow who once worked in a shoe factory in North Brabant province, lives on her own in a Dongen senior complex, visits with neighbors, and sings opera in a choir.

“I’m very bad about being alone,” Schilders said. She remains in good health for now. But looking to the future, she said, “when my health is down, I know I would like to be in Mariaoord” just next door.

Two older women met for a chat in the courtyard outside the Marioord nursing home in Dongen. Ramon van Flymen for The Boston Globe

‘Creating a society without loneliness’

That same sense of community is just as vital for the vast majority of older folks who are healthy enough to continue living independently. And some newly retired empty nesters want something else: smaller housing that requires less upkeep. A range of new options, from luxury to utilitarian, is sprouting up for the older set ready to downsize.

One such community, which opened four years ago in the North Holland town of Anna Paulowna, is called Polder Hofje. Its name invokes principles that underpin the Dutch system and looks to half-forgotten ways of the past for inspiration: Polder, meaning land reclaimed from the sea, is a word also used to describe the country’s consensus ethic. Hofje, a cluster of houses laid out around a courtyard, is a popular architectural style from the 14th century.

Polder Hofje was built, with the help of a government loan, by Jennifer Hofmeijer, a former nurse and emergency medical technician with deep roots in the region. Her goal was to help people age together. “Creating a society without loneliness requires connecting people,” she said.

The two dozen residents at Polder Hofje, who pay rent but have subsidized health care, include tulip farmers and veterans of the Royal Netherlands Navy, which has a base nearby. Many are widows who no longer want to maintain larger houses or farms. Their modern two-story homes are equipped with rooftop solar panels, skylights, and glass elevators, which most don’t need now but expect to in the future.

Resident Elly Korver took the elevator to the second floor of her home at Polder Hofje, a four-year-old independent living complex in Anna Paulowna. Ramon van Flymen for The Boston Globe

On most mornings, there is coffee and conversation at 10 a.m., open to all. “You don’t live alone here,” said Bert van den Heedcamp, 78, a retired Navy engineer. “You can meet people.” There’s usually a nurse on hand who can talk to residents about health concerns.

Hofmeijer freely shares with residents her own expertise and contacts in the medical world. She’s also an unofficial social director. “When I think it’s time for a party, it’s time, and we all party,” she said with a broad smile.

Old age isn’t a comfortable stage in life for everyone in the Netherlands. An immigrant population of more than 3 million, many from North Africa, is often wary of the health system. The vast majority become Dutch citizens after five years, entitling them to the same aging services and long-term care as the native population, but many retain strong ties to their own communities. Some nursing homes cater to different ethnic or national groups, such as Lâle Buurstede in Oosterhout, for Turkish residents, and Raffy in Breda, for those from the East Indies.

But critics say what’s needed is a system that more fully takes into account cultural, religious, and health differences, recognizing some communities may need more resources — including the many immigrants who present earlier with conditions like diabetes and hypertension — rather than treating everyone the same.

“Having an equal approach in health care may lead to inequality,” said Umar Ikram, an Amsterdam doctor and entrepreneur.

There are other challenges. While the Netherlands’ transportation system famously accommodates bicycles, many communities are treacherous for older folks on foot. Peter Alders, a government program manager, is conducting research with Erasmus University on the myriad health benefits of redesigning homes and neighborhoods to encourage walking. “What’s good for your heart is good for your brain,” he said.

Lucie Schilders, who lives in an apartment outside the Mariaoord monastery, walked with a nursing coach in the village of Dongen. Ramon van Flymen for The Boston Globe

Dutch officials are well aware that many aging baby boomers who are now healthy will need help in the future. Given the projected shortage of caregivers, they’re looking to age-friendly technology that focuses on networking and accessibility. The challenge is to move innovations beyond the tech-savvy to the general population.

“We have a choice about how we develop and use technology,” said Tanja Ahlin, a lecturer and researcher at the University of Amsterdam who is studying how people relate to robots, sensors, and artificial intelligence. “It has to be designed in a person-centric way.”

A pilot program in The Hague, the nation’s capital city, is showing the way. Seniors deputized as ambassadors gather at a demonstration apartment — called iZi, a Dutch technology term — to show visitors the latest “age-tech” products: sensors in mattresses to monitor heartbeat and restless movements; lights that respond to movement, illuminating a path to the bathroom; remotes to open and shut windows; coatings to prevent slipping in the shower; even purring robotic cat companions.

George Groet, an 82-year-old former export manager who volunteers at iZi, lives in a nearby apartment and hopes some of the prototypes he demonstrates — from robots flashing medication alerts to hip-mounted airbags that cushion falls — will help him and other remain there for years.

“I want to stay here till I’m 110,” he said.

Groet and other white-haired ambassadors, some retired from the high-tech industry, also speak at senior centers around the city, test wearable devices products, and provide feedback to developers on how to make them simpler to use. City officials fund iZi and decide whether to help seniors pay for the technology on a case-by-case basis, depending on financial need. A tougher challenge is getting people to accept it.

With a robotic cat perched behind, technology "ambassador" Ans Vogelaar demonstrated age-friendly products and bed-rotating techniques in the iZi prototype senior apartment in The Hague.Ramon van Flymen for The Boston Globe

“The word ‘technology’ is a little scary for older people,” said iZi coordinator Aniek Langendijk, a city contractor from a high-tech incubator in Delft. “But when they go to a presentation at a community center and meet the ambassadors, they see what they can do.”

She said the first step is adapting commonly used technology, such as smart phones and video apps, so seniors can talk to families and share photos. “We always say ‘from low-tech to high-tech,’” she said.

One ambassador, Bea Odedai, 71, a former purchasing manager at the headquarters of Dutch conglomerate Phillips in Eindhoven, moved to The Hague to be closer to her children after her husband died six years ago. Introducing technology to other older people has given her a purpose.

“They are afraid of the unknown,” she said. “So when they come here, they can get familiar with the technology. If they know how to make the pictures to send to their grandchildren, they are very glad.”

Ans Vogelaar, a volunteer "age-tech" ambassador, showed off a plant-topped robot in the iZi prototype senior apartment in The Hague. Ramon van Flymen for The Boston Globe

As the nation ages, Dutch officials realize, the sustainability of the country’s social contract could rest on how skillfully they deploy technology and adjust the physical environment for older residents.

Two years ago, The Hague became the nation’s first city to win the World Health Organization’s “age-friendly” designation. It spends over $180 million a year to address the needs of local residents over age 65, who make up 20 percent of the population, said Deputy Mayor Kavita Parbhudayal. The city underwrites technology that can be used at home, as well as accommodations, like benches and wheelchair ramps, that make the city feel friendlier and more navigable to older people.

It would be easy for the old to feel invisible in a bustling capital city of skyscrapers and bicycling bureaucrats, but that’s not the Dutch way.

“We have a very strong belief in societal responsibility,” said Marco Varkevisser, an Erasmus University professor. “We call this solidarity. It’s there, we nurture it, and we like it.”

Two older men shared a laugh in the Mariaoord nursing home complex in Dongen. Ramon van Flymen for The Boston Globe

Research and reporting for this story was part of an International Health Study Fellowship sponsored by the Association of Health Care Journalists and supported by The Commonwealth Fund.

Robert Weisman can be reached at robert.weisman@globe.com.