Because we treat old age as a medical problem in the United States, health care policy change always has profound and far-reaching effects on conditions of life for the elderly. The health care bill currently before the Senate, if passed with its proposed cuts to Medicaid intact, is certain to produce drastic upheaval in the landscape of long-term care. That program is by far the largest source of funding for nursing home stays, supporting nearly two-thirds of long-term care residents. It is worth grappling with just how gruesome the results of cuts to it can be.
The idea that nursing homes are depressing places is an old one. But life inside nursing homes changes with historical circumstance. The age distribution of our population, the structure of the labor market and the design of our welfare state have produced many different configurations. Cuts as aggressive as those proposed in the Senate bill are bound to cause serious damage — and we have real historical experience showing how bad it can get.
It’s now largely forgotten, but a wave of institutional abuse swept through long-term care facilities in the 1970s. In that decade, there were abuse scandals and investigations in California, Connecticut, Illinois, Kansas, Michigan, Minnesota, New Jersey, New York, Ohio, Pennsylvania, Texas and Wisconsin. Reflecting on some of the evidence brought before his Senate subcommittee in 1975, Senator Frank Moss, Democrat of Utah, wrote that what he had heard was “something like a Dickens novel.”
The problem was systemic. Nursing home staff had too much to do in not enough time. At best, this meant neglect: Investigations found patients left in their own filth for days, infections and sores ignored, medical needs unmet and rehabilitation completely out of the question. “The dirt was indescribable,” testified one inspector to the United States Senate about homes she’d seen in New York. A doctor who treated patients from abusive nursing homes said they were often so dehydrated they couldn’t sweat or swallow. “The experience is so common in the hospitals in New York,” he testified, that “if you mention to a colleague that a new arrival is a nursing home patient, it means he is a comatose patient who has bedsores, is dehydrated and has pneumonia or urinary tract infection.”
At worst, patients were subjected to treatment close to torture. In a giant Pittsburgh-area nursing home, staff immobilized hundreds of patients every day because they could not manage their needs. If patients created “extra” work — for example, through incontinence — or spoke out about their treatment, they were subjected to punishment. Among countless such incidents, witnesses described seeing an aide spray cold water on the genitals of an African-American patient with diarrhea while insulting him with a racial slur. A woman named Dorthy, the neediest patient on her floor, had both diabetes and Parkinson’s, and was unable to move any part of her body except her mouth and her eyelids. When she asked for care, “she was screamed at, slapped and told to ‘shut-up’ many times by the staff.” Staff alternated starving and force-feeding her, and, according to eyewitnesses, played with the buttons on her adjustable bed, making it rock back and forth. A patient named Carrie, a blind woman, spoke out about the abusive conditions. The administration sent a psychiatrist to evaluate her, who described her as entirely clear-headed but recommended that she be committed if she continued not to cooperate.