Nursing homes were broken long before Covid-19
Editor's Note: The Moral Economy is a new series that tackles key economic topics through the prism of Catholic social teaching and its care for the dignity of every person. This is the second article in the series.
We live in the age of the aging, and our capitalist economy is struggling to cope. The Covid-19 pandemic has killed over 160,000 residents and staff in nursing homes around the United States, almost a third of total U.S. deaths from Covid-19 thus far. Those numbers raise questions about our treatment of older adults and the utilitarian cruelty of a system that sometimes puts profits before people.
“Covid has laid bare the reality that our elder care system is broken and inadequate,” said Sarah Moses, an associate professor of religion at the University of Mississippi and the author of Ethics and the Elderly: The Challenge of Long-Term Care. “Covid didn’t create a crisis, it exposes a crisis that was already there.”
There are around 1.4 million Americans living in nursing homes, roughly half of whom are long-term residents paying an average cost of around $100,000 a year. This $100 billion-plus sector of the economy, which includes a handful of billion-dollar-plus chains, boasts revenues greater than those of all of America’s professional sports leagues combined. Families routinely liquidate savings to pay for care.
We live in the age of the aging, and our capitalist economy is struggling to cope.
What do we get for all that money? An industry that could not keep its customers safe.
When Christopher Seum died at 74 of “Covid-related” causes on Dec. 19 at a nursing home in Cameron, W. Va., he had not seen his family in five months. “My mom and I tried to get out there, but they had a Covid outbreak, so they wouldn’t let us,” his son David Seum told me. As his father’s health declined, it felt like “all we had were bad choices,” David said.
Health experts and ordinary citizens alike have turned up the heat on political leaders like New York Governor Andrew Cuomo, accused of covering up nursing home deaths. The response increased the likelihood of meaningful changes in legislation and practice.
The principal impact is likely that more Americans will choose to age and die at home. In 2020, the total number of U.S. nursing home residents declined by 15 percent, representing 195,000 people, because of deaths and because people chose to avoid long-term care facilities.
By exposing the disadvantages of nursing homes, the Covid-19 crisis is forcing all of us to ask essential questions.
By exposing the disadvantages of nursing homes that warehouse large numbers of residents, the Covid-19 crisis is forcing all of us to ask essential questions: How can we keep older adults involved in society even if they are not adding to the gross domestic product? How can we learn to enjoy the company of people as they lose their memory, functions and personality and enter what Shakespeare called “the second childishness”? And how can we recognize success when the final outcome is always death?
Overcoming the stereotype that the aging are not useful is one of the great battles in the fight for human dignity in a modern capitalist society. And this is not merely a question posed by a special interest group: We all belong to the aging, and we all need to learn to get through it together.
How did we get here? For millennia, human life expectancy was somewhere between 30 and 40 years. In 1900, it was still under 50 in the United States. And in 19th-century America, the aging were almost always kept at home until they died. Those without families were packed into almshouses, poor farms or asylums.
Overcoming the stereotype that the aging are not useful is one of the great battles in the fight for human dignity.
The discovery of penicillin, the invention of vaccines, improvements in nutrition and the proliferation of soap led to broad improvements in life expectancy. That increase has underpinned an explosion of population growth around the world, to around eight billion today from 1.6 billion in 1900.
And if the 20th century was the age of the most humans being born, the 21st is the century of all of us who were born in the 20th century getting old. By 2050, one out of five Americans will be over 65. And people who live to 65 can now expect to live 20 more years. This is the first time in human history that most people will survive what scientists consider a complete human life span. “In the years ahead,” President George W. Bush’s council on bioethics wrote in 2005, the increased aging “of most advanced industrial societies will be unlike anything seen in human history.”
This is the planet’s future. The United Nations expects the world’s population over 60 years of age to triple by 2050, amounting to one out of five people. By 2050, there will be more people in the world over 50 than under 15. Perhaps that is why in January Pope Francis proclaimed a global day for the elderly, to be held every fourth Sunday of July—July 25, this year—to coincide with the feast of Sts. Joachim and Anne, Jesus’ grandparents. “It is important for grandparents to meet their grandchildren and for grandchildren to meet their grandparents,” said Francis. “As the prophet Joel says, grandparents, before their grandchildren, will dream and have great desires, and young people, taking strength from their grandparents, will go forward and prophesy.”
The United Nations expects the world’s population over 60 years of age to triple by 2050.
Aging societies have been slow to adapt. The passage of the Social Security Act in 1935 provided income for the aged that propelled the development of privately-paid “old age homes.” After World War II, hospitals added beds for long-term care. The arrival of Medicare and Medicaid in the 1960s triggered a boom in nursing homes, as old age homes realized they could make money by offering medical services billed to the government.
A handful of companies built sprawling chains that controlled hundreds of centers and thousands of beds, causing observers to sound the first alarms about dehumanizing treatment. “Increasingly, the elderly depend on persons—professional caregivers, planners and designers of facilities for the elderly—who function at some emotional distance from them,” wrote the ethicist William F. May in his 1986 essay “The Virtues and Vices of the Elderly.”
Genesis HealthCare, for example, operates nearly 400 centers in 26 states and reported revenues of $3 billion in the first nine months of 2020. Over 2,500 people have died of Covid in Genesis homes. The company, based outside Philadelphia, has accepted federal bailout money even as it paid executives bonuses, and it is now contemplating bankruptcy. In a recent letter demanding transparency, Sen. Elizabeth Warren, a Democrat from Massachusetts, criticized the company’s “unfathomable greed amidst a public health tragedy and economic crisis.” In a statement, the company said it was “evaluating” the senator’s inquiry and would “look forward to the opportunity to provide more information and context in our response.”
The problem with for-profit nursing homes is that they incentivize size.
Before Covid-19, profit margins at nursing homes were rising. The problem with for-profit nursing homes is that they incentivize size. “The way you make money is to scale, but when you’re running a facility with 12 residents, you don’t get scale,” said Howard Gleckman, a senior fellow at the Urban Institute. “The real question [for policy makers] is not so much ‘How do you make a better nursing home?’ It’s ‘How can we find alternatives for those who can get better care outside of nursing homes?’”
Making matters worse, although people over 65 vote in large numbers, it is difficult for people in their 80s and 90s to form effective lobby groups to protect their specific interests. Over the past 50 years, people with disabilities have effectively advocated for wheelchair lifts, audible traffic lights and equal employment opportunities. In contrast, “by the time you’re in a nursing home you’ve lost the ability to organize,” said Dr. Moses. Families can advocate for their aging members, but, after the person dies, “the crisis is over, and you move on,” she said.
There are plenty of people who live alone, or with their families. There is a growing body of research that suggests offering practical home support that combines nursing, therapeutical and handyman services can keep people happy and independent longer. Anne Mulderry, 85, lives alone in Manhattan. Her son was killed on Sept. 11, 2001, leaving her enough money to live comfortably. She has eight children, some of whom live nearby. “Family is an inestimable aid in dealing with ups and downs of life,” she told me. “Of course, it can also be destructive sometimes.”
In my own family, when my grandmother Pat was no longer self-sufficient, the family considered putting her in a long-term care home. Instead, my Uncle Earl moved her into a cozy room in his basement in suburban Baltimore and learned to take care of her. Sometimes, as they drank Scotch together, they would call me late at night, and we would all share a giggle. She died a couple of years later, but I recall that time as a special and extended goodbye party that was full of love.
But not every family can afford the cost—or time. Globalization and the ease of highway and jet travel have split families into far-flung tribes. Higher rates of divorce and single parenting have isolated people. “Caring for an aging parent is a rewarding thing to do, but it’s also a costly thing to do, financially and emotionally,” said Mr. Gleckman. “And the fracturing of American families has also hurt,” he added. “Half of children are born to single mothers, so the connection is not there to fathers, and what happens when those fathers need care? The idea of a family taking care of a parent is not what it was.”
‘With our American individualism, we’re just not as focused on the common good.’
For people whose families cannot take care of them, there are movements that try to replicate the intimacy of family care. For example, the nonprofit Green House Project, founded in 2003 by Dr. Bill Thomas, offers a set of guidelines for long-term care that emphasize the social dignity of every member. Its goal is to move away from the institutional model to smaller residences for the aged. Its network includes 300 centers in 32 states.
The Green House Project includes a long-term care facility in Memphis called Ave Maria, which has nine cottages and 100 beds staffed by skilled nurses. In each cottage, the rooms are laid out around a central community living space. “The priority has to be helping folks age with dignity,” said Frank Gattuso, Ave Maria’s executive director. People “want to read the paper while they have coffee and do their own laundry,” he added.
“There are people around here all the time,” said 85-year-old Victor Weirch, an Ave Maria resident. “And I have five brothers and five sisters, and they come to visit me, too, so I never feel alone.”
Even with the best intentions, problems in elder care remain. There is a shortage of nursing staff and gerontologists because those jobs do not pay as well as other medical specialties. And residents face the awareness that aging can mean growing invisibile.
As he has watched fellow travelers die of Covid-19, 79-year-old Joe Hajdu, who lives in a Pittsburgh-area senior living facility operated by the University of Pittsburgh Medical Center, has wondered about the place of older people in society. “I’ve been reading about indigenous cultures among Native Americans and Asians where they really value elders,” the retired Methodist minister told me.
What we value is youth and money. And even though Mr. Hajdu might enjoy reading, playing the piano, talking politics with his wife Cathie and making wisecracks, he knows that our society is built around income-earners.
In his latest encyclical, “Fratelli Tutti,” Pope Francis writes that the elderly have been relegated to “a sad and lonely existence,” part of a society-wide attitude that “it is all about us, that our individual concerns are the only thing that matters.” A truly human and fraternal society, Francis wrote, “will be capable of ensuring in an efficient and stable way that each of its members is accompanied at every stage of life.”
In the United States, Mr. Hajdu has concluded, “there just doesn’t seem to be that kind of focus here. With our American individualism, we’re just not as focused on the common good.”
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