Nursing Home Horrors Lurk Again

Forgive me if I scare you. Bob Dole says I mustn’t do that. The presidential contender talked this week about a “transparent campaign to scare Americans.” One day, he said, we’re scaring seniors, the next day it’s farmers, the next it’s children.

But the problem is that Congress has been rolling over an entire lifespan of programs for the most vulnerable Americans.

One day it is children and the next it is seniors. It’s all happening so fast and furiously that Americans haven’t been scared enough. In the rush of hit-and-run policies coming out of Washington, it’s hard just to focus on one piece of the puzzle.

So try this piece today, the last in the puzzle of life-cycle politics: nursing homes. Try focusing on the 1.5 million elderly Americans who have ended up in these homes. On the federal standards that have made these places safer and have also ended up in the direct line of congressional rush hour.

If the Medicaid proposals pass as they are written, Congress will have deregulated nursing homes and undone its own reforms. We will be fast-forwarding to the past.

Any journalist who has been watching this Congress can come up with a list of stories that will fill the newspaper in 1998 or 1999. One of them is sure to be about nursing homes where the elderly are bound to their chairs, drugged or found lying in their own waste.

This was a scandalous staple as late as the 1980s when studies showed abuse and neglect of the elderly disabled even in state-certified homes. In 1987 the Congress, with the votes of many of these same members, agreed that a stronger federal role was needed. They passed a law setting standards for quality care, a success story by almost every measure.

What has that regulation meant in human terms? Catherine Hawes, one of the senior policy analysts in this field, calculates a few of the improvements this way: 250,000 fewer people tied up, 30,000 fewer people with bedsores, 29 percent fewer people with permanent catheters.

Now Hawes, who grew up as a Tennessee Republican, says with dismay, “I don’t think people knew that the Contract with America said I’m going to tie up your grandmother.”

In America, one out of every three people over 80 will spend some time in a nursing home. The average patient is admitted at 83 with some four chronic diseases. Two-thirds are cognitively impaired, mostly with Alzheimer’s. Two-thirds are incontinent. Half have no living relative nearby.

They have outlived their health, their husbands, wives, sisters, brothers and maybe even their children. And many have often outlived their incomes as well.

Despite our stereotypes, most long-term care in America is provided by families. But when children can’t take care of their aged parents, it may be because “the children” are in their 60s and 70s. When they can’t afford to pay, it may be because they are working to put their kids through school and want to avoid becoming a burden to their own children.

So at moments of crisis, families discover that only Medicaid does what we think Medicare does. It pays for nursing homes. After an elder has spent down her money and become impoverished (perhaps for the first time in her life) by ill health, Medicaid picks up the bill. Nearly half the dollars that go to nursing homes come from Medicaid.

Under the new proposals, at the end of seven years Medicaid will be reduced by 30 percent a year and Medicaid pays half the nursing home bills. You do the math. There’s no way to leave nursing homes untouched.

It doesn’t take a cynic to see the deal that is being made here. Hawes explains it this way: “The Congress is saying to states and nursing homes, we’ll give you less money and we won’t look too closely.” We’ll cut costs, you cut quality.

And by the way, while we’re eliminating federal standards, the House would also like to kill the ombudsman and legal aid programs for the elderly.

There may be ways to cut nursing home costs without providing such an incentive for neglect. But in the coming wrangles over how states will spend fewer federal dollars, the people who live in nursing homes won’t make a formidable statehouse lobby.

This is the way it is now. Another attempt will be made in the Senate to save the regulations. But without public protest or presidential veto, we are about to remake an old nursing home horror story. This isn’t a scare tactic. It’s just plain scary.