The Centers for Medicare and Medicaid abandoned the residents of nursing homes 5 years ago. Now a Wild West of lawless private equity owners—and public apathy—threaten them again.
As Trump appointee Mehmet Oz takes over the Centers for Medicare & Medicaid Services (CMS), we need to remember how CMS abandoned the residents of nursing facilities when COVID struck under the first Trump administration. By means of a waiver of required oversight, the residents were left without inspections for a crucial two months.
Then-president Trump was notoriously opposed to masks. Left without masks or tests, in facilities that were often understaffed by design, our relatives and friends died in appalling numbers. In clusters. Often without a friend or relative at their side. All across the country, if an aide held an older person’s hand and spoke words of love from family members or friends whom the dying person could not be with or even see, that was the best death available.
Many residents, as ever, were not indigent people in long-term care, but were stuck in rehab, paid for by Medicare. But the virus didn’t distinguish.
Why is it so hard to remember the people in the facilities, 5 years later? “It was too sad,” many people will say—and sorrow is also a quick dismissal. Other reasons go deep into the national psyche, and the way the residents were represented by politicians and the press. Beneath it all, experts agree, is the power of the nursing facility lobby in a Wild West of poorly regulated for-profit and private equity owners (pp. 77–78).
Counting the dead shocked us and blurred them. Jacqueline Rose wrote in the London Review of Books, “Counting is a system for classifying the horror and bundling it away.” The residents were being counted (inaccurately, as CMS for months did not require facilities to count their dead) by some dogged journalists. But every numbing statistic ghosted them. Enumerators effectively put them in a faceless mass—112,000 or 152,000 in the first year—eliminating signs of identity like gender or race (see index in American Eldercide: How It Happened, How to Prevent It, which explains why the real number isn’t known).
‘The only thing worse than being counted is no longer counting enough to be counted.’
Counting myopically pushed aside their parlous existential states. For most it was terrifying, like waiting for a bomb to come through the roof. A minority lived in a relatively small number of safe facilities where no one died (1,950 out of 15,400 U.S. facilities). And then there were hundreds of thousands who caught COVID and didn’t die. But the media focus on the mortality numbers may explain why no one thought to count, and then pursue the import of, having so many survivors.
Outsiders—people living in the community, dying in the nation at large—were also counted, but some were personalized. PBS’s News Hour, for example, then delicately moderated by Judy Woodruff, began offering mini-biographies. Her dead had photos, names, a gender, races, ages, hobbies, work, and family members who characterized them lovingly. Music played behind the voice-overs, in a touching piece of journalistic remembrance.
“The Old Die”
The most devastating myth, I argue in American Eldercide: How It Happened, How to Prevent It, was that older adults in general could not be saved. CNN quoted Governor Andrew Cuomo saying that it was “Like watching a fire going through dry grass with a strong wind.” The people were being likened to the dry grass. They were old, sick, “frail.” The counting, with the numbers doubling daily at some points, proved it was futile to think they could be saved.
We other Americans were preoccupied, panicked, isolated, forced out to work or forced to stay at home. Most of us turned away from the category “resident of nursing home”—with pity or relief. Alienation may derive from imagining “the horror, the horror” of the plague inside the facilities. Forced by their jobs to spend time in close mental contact with the new leprosariums, could journalists assigned to that beat also be swept up in the general psychic retreat? This would explain why so many reporters interviewed family members, aides and administrators, instead of interviewing the residents themselves.
Then, once the survivors were vaccinated, their social existence ceased. Massachusetts had one of the highest reported nursing home COVID death rates in the country, with 9,018 [sic] dead. The next day, the state had plummeted it 39%, to 5,502, the Boston Globe’s Kay Lazar reported. Was the Department of Public Health, under then–Governor Charlie Baker, protecting itself?
The only thing worse than being counted is no longer counting enough to be counted.
In 2020, the people trapped inside the facilities were a major story. Rightly, as their lives and well-being were the responsibility of the administration, and they were dying at 23 times the rate of people older than age 65 who were living in the community. Yet as the pandemic continued, the results of compound ageism—forgetfulness, disregard, psychic withdrawal, a sense of futility about saving residents’ lives—became increasingly deep-seated and widespread. Formerly this psychic avoidance went unobserved, but now we can see that it runs deep in powerful parts of the population.
‘Robert F. Kennedy, Jr., new head of HHS, word for word like for-profit industry leaders, described the Biden mandate as a “disaster.” ’
Republicans are taking advantage of public apathy to try to cut Medicaid, which through CMS, supports about two-thirds of the of people who live long-term in the facilities—indigent, and often with disabilities. Mehmet Oz, newly confirmed to head CMS, is a doctor with corrupt ties to various industries. Seventy percent of U.S. facilities are owned by for-profit companies, which often pay huge salaries to CEOs. When private equity takes over nursing facilities, deaths go up.
President Joe Biden, moved by horror, compassion and anger at profiteering, promulgated the first national minimum staffing mandate for long-term care in history, a rise in the care residents receive daily, to 3.48 hours. In his 2022 State of the Union speech, he had devoted a few earnest minutes to the residents’ fates. “As Wall Street firms take over more nursing homes, quality in those homes has gone down and costs have gone up. That ends on my watch,” he boldly declared. This mandate would save thousands of lives a year.
The top experts at the National Academies of Science, Engineering and Medicine grasped that the ultimate issue was power. They wrote, “The pandemic has indeed ‘lifted the veil’ on U.S. nursing homes. The big question is whether the country has the will to do anything about it.” In fact, resistance has grown and will grow to the Medicaid budget cuts. “Hands off seniors” was a sign I saw at the rally I attended on April 5, held by two women in wheelchairs.
Even if the current Republican-led Congress maintained the total budget, leaving the 50 states to determine their own staffing regimes is a known evil. Understaffing leads to neglected turning; poor skin care leads to pressure ulcers, grinding pain, sepsis, even death. Delays in responding to calls lead to falls and broken bones as people with limited mobility try to help themselves. Understaffing is correlated with more use of antipsychotics or (illegal) restraints. The practice was widespread, but Black or Latinx residents were likelier to suffer. Understaffing also leads to infections, a main source of misery, pain, and death long before COVID and since. My home state, Massachusetts, has had a (slightly higher) 3.58 standard. Nearly three-quarters, or 260 facilities, failed to reach it. The state seems unable to compel the mandate.
With Biden gone, Robert F. Kennedy, Jr., new head of HHS, word for word like for-profit industry leaders, described the Biden mandate as a “disaster.” And on April 7, a federal judge in Texas struck down that life-saving nursing staff minimum.
Alienation from the old, the disabled, and the poor haunts us still. We need a national campaign against obliteration—against the unjust dismissal of millions of individuals from the realms of respect and safety, from recognition and quotation, from life itself.
Margaret Morganroth Gullette, a Scholar at the Women’s Studies Research Center, Brandeis, is the author of six books, one of which is the prize-winning Ending Ageism, or How Not to Shoot Old People. This essay merges the latest news with research material from various parts of American Eldercide: How It Happened, How to Prevent It.
