Louis Proyect: The Unrepentant Marxist

September 12, 2005

The political economy of nursing homes

Filed under: Uncategorized — louisproyect @ 1:28 pm

posted to www.marxmail.org on September 12, 2005

In May of 2004 my mother finally went into a nursing home after three years of mounting health problems. Many baby boomers beside me have found themselves coping with the difficulties of looking after aging parents. This generational drama involves intense personal and social pressures. Inevitably, questions of one’s own mortality are posed for the middle-aged son or daughter of a parent struggling to remain independent. When one reaches sixty, as I have, you begin to realize that you too are susceptible to failing health. As one nears retirement age, you find yourself charged with the responsibility of looking after parents who can barely care for themselves. It is analogous to the burden one assumes in raising a child, but without compensating joys. You are also confronted with major economic challenges, since the costs of care for the elderly are enormous in a capitalist society racing to eradicate the last vestiges of the welfare state.

In years past, elderly parents were taken into their children’s home. With the breakdown of rural life, this is no longer the case. Capitalist society is very good at turning people into individual economic actors, but is even better at destroying traditional bonds of solidarity and support.

My mother has adjusted to nursing home life with great aplomb. She has turned her room into something that looks like a college dormitory with houseplants, family photos, a bookshelf and a computer. Although three room-mates have died since she has been there, she has not allowed that to dampen her spirits. With daily visits from her ninety-one year old companion who lives in the next town and access to the Internet and telephone, she feels connected.

Although my mother’s politics are a mixture of the New Deal and Zionism, she reminds me very much of the two main characters in the memorable documentary “Sunset Story.” Sunset Hall, the subject of the film, describes itself as a “non-profit retirement home for free thinking elders who continue to share independence of spirit and involvement in the world.” Now on DVD (http://sunsetstory.com/), this is a story of two women–Irja (81) and Lucille (95)—who make a point of attending as many rallies and demonstrations as they can, on wheelchairs if necessary. When they are not out on the picket lines, they can be found in their rooms consoling each other or bickering about politics.

The film’s website describes them as follows:

Lucille and Irja explode familiar stereotypes of doddering “old ladies.” Sharp-witted, up-to-date, and often provocative, the two are not afraid to weigh in with opinions on men, sex, gender roles, and social attitudes toward the elderly. They operate as a classic comic team, an odd couple, with Irja playing the “straight man,” the eternal idealist and Lucille, the irreverent skeptic, cracking ironic dry jokes.

The movie shows how Lucille faces her final months with both dignity and resignation. It also shows how Irja resolves to carry on despite the loss of her companion. Since very few films have been made about life’s final drama, one can be both educated and entertained by this unique contribution.

It should not come as a surprise that Sunset Hall is facing financial difficulties. This month, the President of the Board of Directors announced that:

It is with some sadness but also a lot of excitement that I write this mid-summer letter to you. Sunset Hall will be leaving its home of some 45 years at 2830 Francis Avenue by October, if not sooner. So many people have lived there and so much richness has been brought to their lives that it is hard to imagine, yet it is simply not possible to continue at that location, with that size of a facility, in the way we have been operating.

The costs associated with care for the elderly are staggering. Since private care is beyond the means of many working class families, the only resort is public care provided through Medicaid. In order to qualify for Medicaid, one must practically be destitute. My mother had the presence of mind to sell me her house seven years ago for a dollar. If she hadn’t, it would have become the property of the state upon entering the nursing home.

Last month the NY Times reported on recently retired Columbia University assistant comptroller Adam Alberico, who was forced to retain the services of “elder-care lawyer” Vincent J. Russo in order to figure out a strategy for using Medicaid to pay for the care of his aging parents. He would have liked to see his mother, who was slipping into Alzheimer’s, go into an assisted living community, but it charged $5,800 a month. His father, plagued by heart attacks, also needed to go into a nursing home at a cost of $7,500 a month. At $13,000 per month, we are talking about expenses that only a multimillionaire could bear. Understandably, Alberico complained, “None of us is fully prepared for this. The cost is unbelievable. And who can figure out the rules and regulations? It’s tough being old and it’s tough being our generation.”

The Times reported on the stratagem many are forced to resort to in the face of such daunting financial obligations:

So Mr. Russo educated Mr. Alberico about Medicaid planning, a series of techniques for disposing of assets in order to meet the standard of poverty required since the program’s creation in 1965 — before anybody anticipated today’s exploding nursing home population. Nationwide spending on long-term care, most of it in nursing homes, has grown to $183 billion annually, nearly half paid by Medicaid, and many techniques for sheltering assets are likely to be restricted within a year.

Vastly more complicated than Social Security and Medicare, the two other insurance policies for America’s elderly, Medicaid is a joint federal and state program with wildly different regulations and reimbursement rates in each state. But each time Congress has tried to fix the system, the new rules seem more confusing, and susceptible to more manipulation, than the ones they replaced.

The Albericos’ Medicaid planning had as its groundwork an abstruse provision added in 1988, known as spousal refusal. The provision, allowing one spouse to refuse financial responsibility for the other, was part of an attempt by Congress to prevent a healthy spouse from winding up penniless paying for an ailing partner’s care. Until the changes in 1988, some elderly couples would divorce to avoid such impoverishment.

For all of its lip-service to “family values,” the Republican and Democratic Parties have no answer to this wrenching adjustment forced on the old and the vulnerable. Fortunately for the Albericos and for my mother, they had children to help them navigate these mine fields.

But the Medicaid safety net is under siege just like every other “entitlement” of the past seventy years. While attention is focused on Bush’s offensive against social security, another attack is underway against Medicaid—formulated as a campaign against “abuse” and “waste.”

On June 30, the Los Angeles Times reported:

Congress is considering a crackdown on financial planning strategies increasingly favored by middle-class families to shift the cost of nursing home care for elderly parents onto the federal government.

Senate Finance Committee Chairman Charles E. Grassley (R-Iowa) denounced the practices Wednesday as “legal shenanigans” and vowed to help stop maneuvers he said were turning Medicaid into an asset protection program, instead of what it was supposed to be — an insurer of last resort for elderly people too poor to afford care.

Since Grassley backs the war in Iraq to the hilt, one must question his ability to judge whether money is being spent properly—to say the least. With expenses on the war rapidly reaching $200 billion, these funds could be better used to provide for the needs of the most vulnerable in American society. The federal government pays for 59% of Medicaid costs, now in excess of $330 billion per year. With an end to the war, money reallocated from killing could fund Medicaid with plenty left over. Of course, the same motivation for continuing the war exists for eviscerating Medicaid: profits take priority over people.

Leaving aside financial worries, there is also the question of how one’s aging parents will be treated in a nursing home. A Lexis-Nexis search on “nursing home” and “abuse,” even restricted to references in the lead paragraph, was fruitless since it is programmed to abort if more than a thousand articles are retrieved. When limited to the past year, it still returned 229 articles! Assuming that this is about average, this means that there over four thousand articles on the subject going back 20 years, the outer limit for Lexis-Nexis.

This excerpt from a July 31 Los Angeles Times article gives some sense of what is going on:

As Gov. Arnold Schwarzenegger’s administration deemphasizes state penalties at California nursing homes, Democratic Atty. Gen. Bill Lockyer is making a point of using state laws to prosecute nursing home owners and their employees who mistreat frail residents.

The state Department of Justice has won convictions against more than 300 nursing home workers dating to 1999, when Lockyer took office. Previous state prosecutors had not focused on elder abuse.

The convictions were for crimes including hitting patients, sexual abuse and using forged licenses to obtain nursing home jobs.

In 2001 and 2002, Lockyer’s office prosecuted two of the nation’s largest nursing home owners: the California subsidiary of Beverly Enterprises Inc., of Arkansas, and Sun Healthcare Group of Irvine. In each case, the state obtained permanent injunctions requiring that they improve care. A criminal case against another corporation, Pleasant Care Corp. of La Canada Flintridge, is pending.

“The people who are their patients and clients should take precedence over profit-taking,” Lockyer said.

At the time of the prosecutions, Sun was the state’s largest nursing home operator, with 80 facilities, and Beverly was second, with 60. Sun and Beverly since have sold many of the facilities.

The criminal case against a Sun subsidiary stemmed from a June 2000 heat wave in which two residents died at a home in the San Francisco suburb of Burlingame, and six others were struck by heat-related illnesses.

The home had a history of poor ventilation and lacked air conditioning. The Sun subsidiary pleaded no contest to a felony elder abuse charge.

Abuse at nursing homes seems as ubiquitous as abuse in prisons. Every so often there are attempts at reform prompted by exposés in the mass media. One of the more notable episodes involved the late John L. Hess, a veteran New York Times reporter and editor who died on January 21 this year. Hess was a friend of Monthly Review and penned a wonderful memoir titled “My Times: A Memoir of Dissent” that I reviewed at: http://www.swans.com/library/art11/lproy22.html. There I wrote:

John L. Hess’s last hurrah at The New York Times was to break the nursing home scandal of the mid-1970s. In keeping with the ethnic peculiarities of the city, most of the crooked nursing home entrepreneurs and their elderly victims were Jewish, including the top gangster Bernard Bergman who had been involved with his parents in importing heroin concealed in prayer books! Bergman’s chief accomplice was Eugene Hollander, who locked patients in their rooms at night in order to avoid paying wages to a night shift. (He billed Medicaid for a Renoir on his wall and told a physician who complained about neglect, “What is a nursing home but a waiting room for a funeral parlor?”)

Hess’s revelations led a local politician, Andrew Stein, to investigate the industry and prosecute the malefactors. Bergman fled the country, but subsequently returned to sue John Hess for conspiring to deprive him of his rights. Eventually, Bergman and Hollander were sent to prison for their crimes, but were able to draw rent from their former nursing homes. Hess admitted that despite all the media attention and all the acclaim he earned as a crusading journalist, “nothing had fundamentally changed.

Are there alternatives to the scenario of escalating costs and institutional abuse or are we condemned to accept them as something unavoidable like the proverbial “death and taxes”? On August 7, the Washington Post reported that Finland’s welfare state has the wherewithal to look after its most vulnerable citizens, young and old, a function no doubt of the fact that “they spend relatively little on national defense.” The Post elaborated:

Finns have one of the world’s most generous systems of state-funded educational, medical and welfare services, from pregnancy to the end of life. They pay nothing for education at any level, including medical school or law school. Their medical care, which contributes to an infant mortality rate that is half of ours and a life expectancy greater than ours, costs relatively little. (Finns devote 7 percent of gross domestic product to health care; we spend 15 percent.) Finnish senior citizens are well cared for. Unemployment benefits are good and last, in one form or another, indefinitely.

No matter how progressive Finland’s welfare state provisions, it is always vulnerable to the kind of attacks that have been mounted in other Scandinavian countries, especially Sweden. In 1995, the Swedish government embarked on a series of cuts that were supposedly made necessary by the perception that social spending was a drag on the economy.

It is not surprising that Marxism has had little to say about the problems of aging since it is imbued with “productivist” conceptions that it absorbed from bourgeois economics in the nineteenth century. This aspect is most pronounced in Trotsky’s 1935 “If America Should Go Communist.” With its breathless paeans to technology and mass production, Trotsky comes across as a socialist version of Ronald Reagan huckstering for General Electric in the 1950s—“progress is our most important product.” His article ends on a most peculiar but revealing note: “While the romantic numskulls of Nazi Germany are dreaming of restoring the old race of Europe’s Dark Forest to its original purity, or rather its original filth, you Americans, after taking a firm grip on your economic machinery and your culture, will apply genuine scientific methods to the problem of eugenics. Within a century, out of your melting pot of races there will come a new breed of men—the first worthy of the name of Man.”

With all due respect to Trotsky and the dubious notion of eugenics, it would appear that much more thought has to be devoted in our movement to restoring the traditional bonds of solidarity and community that preceded capitalism. In traditional rural and farming communities and in indigenous society in particular, the elderly were revered as a source of wisdom and ethics. They helped to define the ethos of the people and explain what a life is good for. The fact that they could not contribute to the economic pot was no reason to cast them aside.

If one of the goals of communism is to recapture the values of earlier communal societies, then we should think about ways that elders can be reintegrated into society rather than dumped in institutions far from sight, no matter how benign.

1 Comment »

  1. It was the sub plot of how Tony Soprano had to deal with his aging mother that really got me interested in that series.

    Comment by Curt Kastens — March 1, 2017 @ 9:46 pm

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