By:

Dave Kingsley

     For-profit, dignified, nursing home care is a contradiction in terms. The widely accepted idea that humans can be commoditized and monetized for investor gain and simultaneously be treated with dignity is nothing more than a comforting fiction. Contemporary management culture treats fiduciary responsibility to optimize shareholders’ returns as a normal community standard. Nursing home owners and managers operate squarely within this ethos.  Therefore, humans needing care will of necessity be devalued.

    The elevation of shareholders’ rights above the rights of all other stakeholders – patients, communities, customers, even the broader public – was not the result of random circumstances. It is the predictable outcome of agency theory, the management doctrine that took hold in the 1980s and redefined a manager’s ethical duty to owners alone.   This worldview has become so normalized across the industrialized economy that its consequences are met with resignation, if not indifference, by the media and the public. Yet its effects on publicly funded care systems are profound and corrosive.

    Agency theory is incompatible with humane publicly funded health care in general, but it manifests in its ugliest form in a nursing home setting. These facilities care for people who cannot advocate for themselves, whose well-being depends on labor-intensive, relational, time-consuming human attention. Under a shareholder-first model, those needs are inevitably subordinated to investor demands.  As finance has shifted from supporting the mission of care to becoming the mission itself, the rights of residents have been incrementally and increasingly sacrificed to return on investment.

    Attempt to reform the nursing home system is counterproductive for the simple reason that it sends messages that the system is a legitimate form of caring for the elderly and disabled. All that can be accomplished by tweaks is a false belief that the system will become fundamentally what citizens in a civilized society think it should be. That will not happen. The promise of reform becomes a kind of industry induced fantasy, reassuring the public that the system is on a path toward decency when it is structurally incapable of delivering it. In this way, reform does not challenge the system’s legitimacy; it reinforces it, allowing a fundamentally extractive model to masquerade as a form of care.

    Rather than attack the illegitimacy of the system, advocates and the media look for bad actors who, they believe, could be eliminated for the purpose of transforming the current, normalized mode of organizing and caring for nursing home patients. By isolating the problem to a handful of villains, the public is encouraged to believe that the system can be redeemed once the “worst actors” are removed. But the very conditions that produce neglect, exploitation, and suffering result from the financial and organizational logic of the industry. The search for bad actors is a diversion that hides the underlying structure from scrutiny and allows the cycle of harm to continue uninterrupted.

    These patterns reveal a system in which care “failures” are systemic and structural – not a system in need of better oversight or more competent operators. In reality, the nursing home industry as a whole is a tragic failure propped up by fantasies of total reform through democratic processes. Widespread dehumanizing care in the publicly funded long-term care system is the predictable result of organizing that care around financial extraction, opacity, and lack of accountability. As long as this model remains intact, no amount of reform will produce the dignity, safety, or freedom that a democratic society owes its elders and disabled citizens.

    Confronting the reality of widespread abuse, neglect, and indignities is an act of political clarity and courage. It allows us to see that the crisis in long‑term care is not due to technical problems that can be tweaked away, but as civic failure—a question of what kind of society we intend to be. A democratic people cannot outsource care to a structure that negates the very conditions of democratic life: reciprocity, transparency, shared responsibility, and the possibility of new beginnings. The task before us is not to perfect an illegitimate system but to replace it with forms of care that honor human dignity and restore the bonds of democratic belonging.