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Despite nearly universal health-care coverage for older Americans, the quality of care for the sickest and frailest remains sub-optimal. Understanding why requires analysis of the medical ecosystem. This paper considers the role of four of the principal actors in this system: physicians, hospitals, drug companies, and Medicare. Physicians spend more time in the office addressing diabetes and hypertension than they do evaluating falls and impaired cognition because of their training and their interests. Hospital administrators affect the hospital experience by investing in procedural specialties at the expense of low-tech, high-touch care. Pharmaceutical companies affect the medications older patients take by direct-to-consumer advertising and marketing to physicians. Medicare affects the patient's experience by prospective payment for hospitals, resulting in the burgeoning of post-acute care to accommodate early hospital discharges. Determining how to improve the quality of care for older people requires identifying a lever that affects the entire system. Medicare is uniquely positioned to serve this role. Reforming Medicare by introducing cost-effectiveness criteria for reimbursement of expensive devices, by instituting requirements that medical resident training programs include exposure to multidisciplinary team care, and by introducing a new benefit package for the frail elderly could improve American geriatric care.