The Nursing Home Dilemma

Last night I was flying home on Southwest Airlines. As so often is the case on a Southwest flight, the steward made a humorous announcement. He advised that, in the event of an emergency requiring oxygen, if you have more than one child, first place the oxygen mask on the child least likely to place you in a nursing home. As I listened, I thought of Jim B.

Jim B. was my father-in-law’s roommate during his one-month nursing home stay. Fortunately for my father-in-law, his condition improved and he was able to leave the home and join his wife in an assisted living apartment.

Although my father-in-law’s situation had a happy ending, it is an unfortunate truth that for many, a nursing home stay is a life sentence. What is also true is that many of these individuals are limited physically but have almost full mental capacity. Such is the case for Jim B.

There is little privacy for the residents of this nursing home. Their living space isn’t much more than a cubicle. There is little in the way of activities. Most lie in bed and watch television.

Some of the residents of the home are there because of strokes or heart attacks, yet the menu consists of meat at almost very meal. Vegetables and fruits are mostly canned. This is institutional food at its worse.

On the door of the room shared by my father-in-law and Jim B. was a preprinted sign with Jim B’s named filled-in. It read “Happy Birthday, Jim B”. There was nothing personalized about the message. Other than a pre-printed signature “from the staff” the poster was not signed.

To say this home is an unpleasant place is an understatement. To say that nobody would choose to end their life in this place is an understatement. To say that many families make heartbreaking choices is an understatement.

I am not critical of any choice a family may make. But I do know this: The incentives that the federal government provides has the effect of institutionalizing some of our senior and disabled citizens who could function at home and whose families would rather that they be at home.

Medicaid programs that cover individuals with low incomes or disabilities automatically pay for nursing homes. It’s up to individual states to decide how much they will pay for in-home services. According to the Wall Street Journal, few states fund the level of skilled care that many would need. This relative scarcity of funding is also true for assisted living situations.

The irony is that assisted living or home care would cost the taxpayers less than a nursing home. The Wall Street Journal reports that the state of Georgia, for example, spends about $81,000 a year for each resident in institutional care, including nursing homes. By comparison, home and community care costs about $26,000 a year.

Government funding creates perverse incentives. For this problem, I have no ready answer. I would be the last to argue for a new entitlement program. Yet clearly there is something wrong in this bias towards institutionalized care.

Although there are many who seek other choices, on balance this bias towards institutionalized care seems to grow. For example, many support a new entitlement of universal pre-school and day care for children. Many others support further expansion of government provision of health care services.

I find this bias troubling and puzzling. We all have had enough experience with the low level of services provided by unaccountable institutions and bureaucracies. In spite of our experience, somehow we believe that the new program we advocate will be done better and more efficiently. Until this societal belief changes, the programs politicians advocate will not change.


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