Nursing homes present an increasingly profit-driven industry, one that has attracted private equity. From conservatives’ vantage, the industry is hindered only by a meddlesome Uncle Sam from thriving.
And yet, conservatives, especially those with family in nursing homes, acknowledge the grim reality: too-few staff. The paucity of staff seems a fact-of-economic-life, much like the inflationary cycle. We want to trust that something will happen — maybe a recession? — and nursing homes will have a surfeit of applicants
The reality is not yet horrific. No Pulitzer-worthy exposes, at least not yet. The decades-old scandals that spawned Pulitzer exposes have passed. Libraries have archived the tomes — “Tender Loving Greed: How the Incredibly Lucrative Nursing Home ‘industry’ is Exploiting America’s Old People and Defrauding Us All” (by Mary Adelaide Mendelson), “Unloving Care: The Nursing Home Tragedy” (by Bruce C. Vladeck), and “Too Old, Too Sick, Too Bad: Nursing Homes in America” (by Frank Moss). Today the problem is no longer the inept, ill-trained, abusive staff, but not enough staff. Yet the correlation of staff with “quality of care” is inescapable. The lower the staff-patient ratio, the worse the care.
Now, to improve quality, Uncle Sam has upped the staffing standards. Since Medicare and Uncle Medicaid pay a hefty chunk of the nursing home tab, Uncle Sam felt a paternalistic interest in seeing that the government’s patients were treated well. The new standards were crafted to improve care , but the Centers for Medicare and Medicaid Services estimated that if all facilities embraced those new standards (3.48 hours of care daily per patient), 3,200 homes would have to hire almost 13,000 more registered nurses.
Whenever conservatives contemplate a solution, those solutions jar with conservative principles.
The simplest solution: raise wages. The homes need to raise wages and benefits to lure staff. Coincidentally, and understandably, the fewer staff on board, the more onerous the work-load — which leads to even fewer staff.
Yet conservatives, intent on protecting businesses from onerous federal mandates, are torn. On the one hand, conservatives understand facilities’ ire. The trade group, the American Health Care Association, argues that many homes are barely able to hire staff as is … asking them to increase staff risks financial suicide. In a for-profit world, moreover, capital is fungible; and investors can move their capital easily. When a nursing home closes, ultimately those who suffer are the current and future residents. In Uncle Sam’s zeal to improve care, he might reduce it. On the other hand, conservatives understand families’ anguish. Perhaps pragmatism rules: mediocre care is better than no care.
Immigrants are another plausible solution, but one that puts conservatives in an existential bind. Many immigrants — documented and not — in this country fill jobs that native-born Americans eschew. Forget the populist “deport-them-all” rhetoric: a week without immigrant workers would plunge the economy into chaos. And the chaos would be especially dramatic in health care. Nursing homes already depend on international nurses. Perhaps they should expand their outreach, their incentives? That of course might entail relaxing immigration regulations.
So the conservatives who care about their parents’ care (and their own care-in-the-future) face a dilemma. To stay true to their xenophobic worldview, they want to stymie immigration; to help facilities, they should increase the non-native population. Again, a subtext is clear: maybe less-than-optimum care might be better than inviting onto our shores more foreigners.
The “tech” solution that has replaced bank tellers with ATMs, clerks with self-scan machines, and overall administrative staff with apps will not work for nursing homes. We might want AI to solve the problem, but it won’t. (In fact, the assisted living industry blames “bad” algorithms for staffing shortages (Washington Post). It wasn’t the accountants that made them stint on staff: it was the algorithm. The usual cost-effective strategy calls for substituting less skilled for more skilled staff, but nursing homes have been doing that. Staff need to help residents bathe, dress, eat, ambulate; staff need to distribute medications. The geniuses behind computers cannot craft technological solutions.
Back to the obvious solution: higher pay. If facilities paid better wages, with sick leave, health insurance, vacations, and pensions, the job fairs would fill. Again, conservatives confront a dilemma. Higher pay is key, yet higher pay will depend on upping Medicare and Medicaid reimbursement — which translates to higher taxes. And “higher taxes” remains taboo for conservatives. That group has been pleading, incessantly, for lower, not higher, taxes. Benefits too remain a conservatives’ challenge. If the nation guaranteed affordable health insurance, the facilities might get away without offering health insurance. But any kind of government-financed health insurance is another taboo. Ditto for housing subsidies. Lower-income workers struggle to find housing that they can afford; government subsidies would help — another conservative taboo.
Finally, maybe caring for the elderly and infirm should not be a “for-profit” industry ripe for equity investors. Maybe we need more homes that are “mission-driven,” not profit-driven. This admission that the corporate world cannot solve all social problems marks the greatest challenge to conservatives.
Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email joan.retsinas@gmail.com.
From The Progressive Populist, July 1-15, 2024
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