The proportion of the US population over 65 years old is increasing dramatically, and the group over 85 years old, the “oldest old”, is the most rapidly growing segment. People who survive into higher ages in America, which itself is an aging society, face a suite of competing forces that will yield healthy life extension for some and life extension accompanied by notable increases in frailty and disability for many. We spend more, for worse outcomes, than many if not all other developed countries, including care for older persons. Looking forward, our health care system is unprepared to provide the medical and support services needed for previously unimagined numbers of sick older persons, and we are not investing in keeping people healthy into their highest ages. This paper summarizes the opportunities for valuable policy advances in several important spheres that are central to the health and well-being of older persons. In all of them, concerns regarding disparities in health and the severe concentration of risk among the poorest and least educated members of our society present special opportunities for progress and these issues are addressed in detail in other papers in the Vital Directions series.