This is fantastic. The nursing home industry is dirty and sad, with for-profit groups squeezing every cent they can out of seniors who can't advocate for themselves, out of their families, and ultimately out of the taxpayer. They do that by poorly staffing their homes, and by creating networks of other legal entities that charge the home money so it doesn't make a profit.
For example, a holding company might own the nursing home operator as well as the building owner who charges them exorbitant rent, or the service providers selling into the home. If I had one piece of advice for someone with aging parents: find a non-profit home if you need a home at all. The sisters of mercy, the Jewish community homes. For-profit nursing homes are to our era what insane asylums were to the 19th century. A horrifying disgrace.
This is where the government could step in and provide nursing homes. They already end up paying for most of it via Medicare, why not have more control over quality and standards. You could even trial it via a (much needed) VA nursing home program for vets
Think about what you're saying for a second.
You're advocating for the same government that has had the ability to regulate nursing homes for the last few decades, and failed to do so, instead be given full control over nursing homes?
You're suggesting that the politicians who had the power to fix the problem and did nothing instead be given more power?
That's such a self-obviously bad and self-contradictory idea.
The solution to bad government is better government not less government
Yes. I wish we'd move on from the tired more/less government debate and focused on better government. But neither party seems to care.
Does better government imply current government employees losing or having to change jobs? That’s sort of not possible at scale.
Not sure what you're implying but in my mind getting rid of government unions would be priority #1.
The government is controlled by the government, not voters. The government has incentives to stay the course. Every single government employee wants to keep their job, managers want to keep their teams/projects/products. The government downsizing itself amounts to hundreds of thousands of individuals collectively deciding to act against their own interests on behalf of some abstract notion of what’s best for hypothesized future citizens. Not going to happen. Workers are workers. The government is first and foremost a workforce.
You're implying that less government should be the goal. I don't care about the size, i want better government.
I didn’t connect the dots, sorry. Say a government agency needs to be better, like DoT for instance. How will you make DoT better? Every president puts a new leader in, buttgieg has some authority, but most DoT staff have been there forever. He can bring in some of his own people, maybe “manage out” (bully till they resign) those who don’t adopt his agenda or conflict with the people he brought in. But for the most part, DoT is going to keep doing what it does, same managers managing the people, doing the same work, protected from firing by American labor laws, and so how do you “make it better” without firing a lot of people, or moving them around, all at once?
The vast majority of the time less government is better government. If it’s not going to be less, it’s better when it’s local.
Block grants federate and localize solutions, limit the damage of poor choices, and force answers to tough choices.
Federal programs with centralized oversight end up spending too much for too little results and will never be able to efficiently solve these problems.
And also: the solution to bad government is better government, not more government.
It would still be bad and a failure but it would be cheaper so why not
Because it would not necessarily be cheaper. The government can be incredibly wasteful and inefficient, especially when corruption is involved - and the money still comes from you! The fact that the costs are coming from your taxes and in the form of more expensive goods and services and decreases wages due to inflation makes the costs hidden, not lower.
Personally, I've come to the following conclusion after dealing with the American health care system far to much in the last three years and several encounters with corporate America throughout my adult life:
There is no difference in the potential for waste, inefficiency, fraud, corruption, laziness, and outright stupidity between government and private systems. There is a difference in (1) my (and my fellow citizens) ability to influence between that two and (2) not having to pay for profit and the costs to me resulting from necessary profit on top of the rest of the shit sundae.
As someone who has actually worked for both the US government and the private sector - this isn't true:
The inefficiency that I saw in the government was far greater than that of the private sector.
To some extent, it had to be - the government has to be extremely reliable and accessible (while most companies content themselves with 99.99% website uptime, or only serving people with a mailing address, or whatever - the government has to serve everyone and be available as much as possible), and that's a good thing.
But beyond that, factors such as extreme risk aversion (which generally grows with the size of an organization), gross incompetence, and outright corruption made the government far less efficient than what I experienced in industry - to the point where it was an old-and-not-funny-anymore running joke among my government colleagues.
Moreover, the government also holds massive influence over your life that corporations do not and cannot: taxes, monopoly on violence, control of the legal system, ability to enact and enforce regulation, and many more.
It should be pretty clear that separation of powers is a good thing, and only an idiot would decide that it's better to consolidate as many things as possible into a single central entity that also uniquely holds all of those powers.
Ability to influence? Yes, you have ability - but the amount of actual influence exerted on government in the US is minimal. Public opinion in the US has almost zero correlation on the law[1]. The political process is overwhelmingly dominated by a small amount of wealthy and powerful individuals and special interest groups.
It's absolute insanity to take this mess and put more things in control of it.
Well, as we've already established, the government is significantly less efficient than industry - and even if it wasn't, the extra margin that you have to pay is a trivial price to the utterly insane alternative of the government controlling all private industry.
[1] https://act.represent.us/sign/problempoll-fba
there's no private healthcare system in the US, except for maybe the individual mom & pop doctor's offices.
Every other player is
- getting handouts from govt (hospital non-profit statuses from all taxes incl property taxes, payouts for invented"losses"; payor premium subsidies),
- protections from competition (PBM "discounts", Pharma IP evergreening rules, hospital requirements to approve new local competitors, payor lobbying for regs to prevent "lite" plans )
- and are very much flirting with antitrust action (payor & pharmacy vertical integration, cutting off contracts of any remaining independent doctor/vendor holdouts etc).
Just think about it abstractly. Variation decreases as n count increases. Large organizations will tend to be similar. As you note most large private systems end up behaving similarly to large public systems in terms of corruption, inefficiency etc….
But notice that it’s driven by the n size. If you look across smaller systems, you’ll notice they are more diverse. Like startups. Smaller n means more variation. Occasionally a small variation or mutation will push evolution forward. Public systems are generally to large and risk averse for that sort of evolutionary adaptation. At least at present. Maybe we can make public sector more like startups by changing how tax dollars are spent, not necessarily changing the amount spent, but the way it’s spent? I don’t think we’re there yet.
https://en.wikipedia.org/wiki/Principal%E2%80%93agent_proble...
I'm not sure the VA is a good example to hold up. Aren't VA hospitals notorious horror shows?
VA hospitals have outperformed private hospitals in patient satisfaction for at least a decade.
https://www.npr.org/2023/06/14/1181827077/va-hospitals-healt...
I'm curious how those surveys are administered. If they're not surveying patients that walk away or don't get treatment then they aren't really capturing the full picture. Unlike private hospitals the VA is obligated to serve all veterans and it's the portion that they miss or manage out that became problematic national news. There's a reason Obama passed legislation allowing veterans to seek outside care and it wasn't always wait times. It also had to do with VA guidelines, standards, and practices which very much differ from private care.
It’s possible that all kinds of things skew the results. It’s possible that veterans are more likely to report that they are satisfied in general.
But there have been numerous studies comparing the VA to private hospitals that show the VA tends to be safer and more effective as well as having higher satisfaction scores.
People are constantly complaining about other health systems like Kaiser and private insurance companies as well. The VA is the countries largest health network and veterans are a very symptomatic group.
My guess is that if you changed history so that Kaiser was in charge of veterans healthcare, with the same guidelines and standard of care they use today, you’d have seen a similar law passed.
Yeah, I'm not buying it. My experience was bad and I've met many people who've had it worse there.
Again, it's the process and bureaucracy. The standard of care, when you get it, is mostly adequate but navigating their system is absolute hell. I suspect they're narrowly defining these studies to standard of care.
That could be the case. Here’s a meta study with links to all of the individual studies if you want to look deeper.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5215146/
But I know plenty of people who say the exact same thing about Kaiser. I know plenty of people who say the exact same thing about medical care in the US in general.
Thanks for the link. They are only studying actual care provided. That's definitely going to fly right over the issues at the VA.
I've used Kaiser before and the system is nothing like the VA system. Are you a VA member or are you just trying to normalize it against something you know?
That could set the stage for a Canadian situation where if you complain they offer death as an option.
https://beta.ctvnews.ca/national/politics/2022/12/2/1_617932...
I think it’s more likely to set the stage for quality nursing homes.
Maybe it could be opt-in. Elect to pay a little bit extra in taxes. Then you get to go to the government home. I’d fully support that.
In reality, people don’t really care much about very elderly people. Not even their own families most of the time.
Ignoring the question of whether the government should actually be involved in this, I don't really see why this specific aspect of society should be opt-in. Basically all things provided by the government are used at different rates (or not at all) by different citizens so I don't see why that reasoning wouldn't lead us to making all things in society be opt-in. Some actually believe that sort of idea makes sense, but I certainly do not.
In any case, the government could surely just regulate private nursing homes much more strictly making many of these parasitical companies' business models untenable.
Works great until the next politician in charge reenacts privatization and retires with a sweetheart position on the board like this:
https://www.theglobeandmail.com/business/commentary/article-...
Warren ran on a platform in 2020 that had some good systemic solutions to issues like that. We have the power to regulate, we have the power to regulate the regulators. We don’t have to accept the way things are now is the way things will always be.
Basically: instead of this being a “can’t do it because of X” how about “let’s do it, but make sure to fix systemic issue X from happening too!”
Of course! I'm not saying it should be done, it absolutely should. There's no place for profiteering from people's health like that in a civilized society. Just that making it public is not the end of the story either.
I had a comment here that described the committees that people could write to in order to change things, but it got voted down to zero.
I appreciate the gesture but this is not a good idea. The VA's funding, as well as programs administered by the VA, is subject to tit for tat battles in the House Appropriations Committee. That's to say, it will get gutted over time if you create it. When it is gutted the two sides will create competing narratives of which you will never be able to discover truths from. This has been happening for generations and the VA frankly isn't that old.
Example:
- https://appropriations.house.gov/news/blogs/democrats-vote-a...
- https://democrats-appropriations.house.gov/news/press-releas...
The unwillingness, on all sides of political spectrum, to provide physical and psychological support to former military members in modern democracies is something that completely baffles me.
In Canada, at least, no-one wants to join the military because it's a shit job with shit pay, and what we end up with is a small contingent of volunteers who are either a) highly idealistic or b) excited to commit war crimes, and that is why the Canadian Airborne Regiment is no longer a thing.
why not have more control over quality and standards
In theory they do, since eligibility for getting paid by Medicare has requirements. Unfortunately, there are too many vested interests influencing the process in the "government oversight is pure evil/of course we can police ourselves" direction.
Even the non-profit ones are really expensive. E.g. Jewish Living in SF has ~$15K/month for long term skilled nursing care. It's a very good one but has a long waiting list.
Assisted living and nursing home are just very expensive. The prices around the Bay Area ranges from $5K/month to $20K/month.
Holy baloney that's expensive. What can you do when your elderly parent is suffering from dementia and can barley walk anymore and neither you nor they have that kind of money to spend?
Assisted living or skilled nursing homes are for the “rich.” People sell their home to finance the cost. At the end Medicare picks up the cost.
In some states, there is something called a Lady Bird Deed. It lets people keep their homes while still being eligible for Medicaid. Plus, it avoids the probate process.
https://www.nerdwallet.com/article/investing/estate-planning...
Bankruptcy. Not for the elderly person, because elderly have protected federal income. But bankruptcy for the children who are on the hook due to filial responsibility laws in most states.
I agree, but does Sisters of Mercy provide skilled nursing?
Compared to which other nursing home? If you're going to take a jab at something you should compare it to what you consider "skilled nursing"
Doesn't matter where you go, a nurse still requires state licensing and testing...
The workers doing all the grunt work are STNAs, or, state tested nursing assistants, which again, doesn't change regardless of facility.
“Skilled nursing” is an industry term for the services provided to elderly people who are not able to live semi-independently, and need daily nursing care for health issues or significant degree of mental decline.
I think you misunderstood me, or I'm not sure how you got the impression I'm taking a jab at anybody. TFA pertains to nursing homes (a.k.a. "skilled nursing facilities"), not personal care homes or assisted living. Sisters of Mercy seems to fall under one of the latter categories, so the poster to which I responded may have conflated the two. Obviously, Sisters of Mercy has nurses (who are skilled) working for them. I was only curious whether they provide care that can't be obtained at an assisted living facility, such as IV meds and ventilators. But they aren't listed by the ProPublica tool, so that probably answers my question.
Yes.
Do you find skilled nursing in this facilities? No.
It doesn't seem very "complete" in that Nevada was listed as having exactly 4 nursing homes?
Seems accurate. The rest are likely just classified as casinos.
This is such a perfect comment, it seems snarky and yet a Casino has so much in common with a nursing home, constant surveillance, on site medical team, "activities" and "food" 24/7, and if you spend (lose :-) enough money they will give you a place to sleep for "free."
Non profits engage in profit prioritizing ways as well
Removing shareholders is a good incentive model, but the organization still needs to be evaluated on their efficacy
Non-profit nursing homes are a great option for many people. But they usually have long waiting lists. And many are unable to deliver the necessary level of care for patients with neurodegenerative diseases like Alzheimer's. Those patients often have behavioral problems and are difficult to manage.
I'll add another adjacent niche:
Addiction & recovery and mental health centers.
Sometimes you win and you get better, but it comes at a very very steep cost (and there's no refund, of course).
Absolutely. I work as a paramedic. It is utterly infuriating to see nursing homes whose policy (they claim their liability insurance, but I suspect it is often laziness) is to call 911 for anything bigger than a bandaid and expect us to take care of everything going on...
... while there's a huge billboard out front, "Round the clock nursing care!" and they're happily billing the patient/family five digits a month.
And then I search a few in my area that are the worst offenders, and find that several have been repeatedly sanctioned for "failing to have an RN supervising care" (so you have maybe an LPN watching over a couple of dozen CNAs...)