In the last 100 years, American orphanages have dramatically declined at the same time as nursing homes have seen exponential growth. This paper reviews the common understanding and assumptions about these two distinct histories and asks: why have these national responses been so different when the populations at the center of them are so similar? Among several reasons offered for these differences two unique factors that promote the institutionalization of the elderly are commonly omitted. These are: the gendered nature of institutionalized elderly populations and the stigma and social burden of death and dying. These two influences, separately and together, are either overlooked or underestimated for their impact on historical and policy outcomes. It is crucial for the future of elder care and research that these factors are recognized so that policies have a precise – and more helpful - focus on the actual challenges faced by these populations.