A commission to study the nursing home system, conducted under the auspices of the National Academies, of Science, Engineering, & Medicine (NASEM), recently released its report entitled The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. The report included a very brief history of the nursing home system – a 400-year history reduced to a couple of pages. Furthermore, it is a history that will not upset officials, proprietors, investors, executives, politicians, and others who are benefitting from the status quo.
Basically, the commission is feeding the public historical pablum. Left out of the multi-century account are such salient features as ongoing and intensifying financialization, and pivot points such as the 1950s-60s’ development and codification of “the medically indigent,” the role of states’ rights, and the influence of racist, segregationists. Also excised were many significant changes of 1980s-90s such the transformation of macroeconomic and corporate philosophy from managerial capitalism into what is known as “agency theory,” – basically meaning that shareholder value is not just the highest ethic of capitalist management but the only ethic.
Between the late 1990s and early 2000s, capital markets and tax codes were conducive for the entry of real estate investment trusts (REITs), private equity (PE), and other corporate legal structures (e.g., limited liability companies or LLCs) into the senior housing market. Large pools of capital had been accumulating through pension, college endowment, sovereign wealth, and insurance funds that needed to flow into businesses that would provide desired yields and return on investment. These funds are managed by institutional investors such as Vanguard and BlackRock. The number and size of publicly listed companies have grown considerably over the past two decades as REITs have expanded their power and financial dominance in the senior housing market. To ignore these players in the industry is to ignore the proverbial 800-pound gorilla in the room.
These changes have been accompanied by massive investments of cash into political campaigns and politicians’ coffers by PACs, Corporations, and lobbying firms representing the medical-industrial complex, Wall Street, and real estate. What worthwhile history would tiptoe around the corruption wrought by money in politics?
It is easy to become known as a radical and marginalized. Taking a hardnosed stand regarding the truth is an annoyance. History is written from a “point of view” of the powerful and their version of events. They choose the people, places, and things to include and exclude. Challenging those points of view will typically evoke hostility. This is currently noticeable in the backlash to “critical race theory.” African Americans would benefit greatly from a factually accurate history of race in America, which would facilitate an honest look at institutional racism still pervasive in the United States – including in the nursing home system. It would also be helpful to the elderly to have a movement that could be called critical elder theory – perhaps CET would be an appropriate acronym.
Unfortunately, humans are beset with psychological defense mechanisms that serve the avoidance of truth and lend support to the creation of a comfortable reality. There are many defense mechanisms recognized by psychoanalysts. However, four main defenses in history: denial, rationalization, repression, and fantasy are essential for understanding how official bodies such as commissions paper over reality and prevent real change.
Fantasy is seeing the world not as it is but as the way we would like it to be. No American wants to think that the elderly, as humans, are only worth what the treatment in a typical nursing home would suggest. We believe we are better than that. Our creed does not permit widespread shortening of life and suffering because of financial considerations. Somehow the incongruence between our creeds and our deeds must be reconciled. So, we retreat into a fantasy world in which medically fragile and frail elderly and disabled persons are living in as system with a few tweaks can be fully staffed and made into a “home-like culture” (a vague term if ever there was one).
Fantasies can only be maintained through denial of reality (out of sight-out of mind), repression (just don’t think about it), and rationalization (Medicaid reimbursement is too low). Human nature being what it is, these defenses operate mostly at a subconscious level.
Window dressing called “home culture” as it has been conceived and implemented thus far will not substantively change the structure and function of the nursing home system as it has evolved. However, it will assuage our consciences.
 National Academies of Sciences, Engineering, and Medicine 2022. The National
Imperative to Improve Nursing Home Quality: Honoring Our Commitment to
Residents, Families, and Staff. Washington, DC: The National Academies Press.