Review:  "What Happened in Room 10", by Katie Engelhart, California Sunday Magazine, August, 2020 with all due respect to the compassionate careworkers at all levels and to those who have died living and working in nursing homes during the pandemic.

The COVID-19 virus has revealed the failure of our US healthcare system, especially the care of older and disabled people needing residential care in nursing homes and other long term care facilities. We are eight months into the pandemic and have no centralized strategy guiding facilities in their response to the virus. Advocates for residents of nursing homes, including Geriatricians, non-profit program administrators, academic Gerontologists and Health Policy “experts” have been actively trying to influence the Federal response to the nursing home crisis by convening panels, committees, task forces, and writing recommendations, white papers and Op-Ed pieces to examine practical responses that are needed such as testing of residents and staff, infection control training, and adequate PPE supply.

Meanwhile lobbyists for the nursing home industry have succeeded in getting legal immunity in several states for the time period surrounding and during the pandemic. Even before the pandemic, the lobby requested and received easing of regulations and fines from the Centers for Medicare and Medicaid (CMS). This immunity and easing of regulations is in addition to the fact that the top-ten nursing home companies had already split themselves into real estate and operations limited liability corporations, making it much more difficult for residents’ families to successfully sue for negligence. 43% of COVID-related deaths in the United States have been in nursing homes. In spite of the task forces and calls for reform, the response has been about protecting the owner and investors, not about protecting residents and staff.

While immediate reforms to improve conditions of care are necessary, a radical critique of the mainstream response to the nursing home crisis is necessary because none of these responses address what the COVID virus revealed about the systemic failure of the healthcare system that is increasingly run for profit rather than need.

One mainstream response is particularly interesting in that it appears to be a radical critique but falls into reformism, a good example of how the neoliberal system attempts to control the discussion of this crisis.

In March, 2020, the first widespread COVID outbreak in a nursing home occurred in a Kirkland, Washington facility owned by the large nursing home chain, LifeCare Centers, based in Tennessee. A lengthy expose called "What happened in Room Ten", was published in the August, 2020 issue of California Sunday magazine and was praised and shared widely among the professional and academic Gerontology and Geriatrician community on social media. To better understand and critique this article, a little background for both the publisher and the writer, Katie Engelhart, is helpful.

California Sunday was established in 2014 as an insert with Sunday editions of the LA Times, NYTimes, Sacramento Bee, San Francisco Chronicle, and San Diego Union- Tribune. In 2018, California Sunday was acquired by the Emerson Collective, a “social change” organization founded by Laurene Powell Jobs, widow and heir of Steve Jobs, and now a billionaire. Emerson Collective is also the majority owner of the Atlantic magazine.

Katie Engelhart is a 2018 “Eric and Wendy Schmidt Fellow” at New America, a “think and action tank dedicated to renewing the promise of America, bringing us closer to our nation’s highest ideals”... an “incubator for policy experts and public intellectuals” for a “renewed America” (from their website). New America’s board members include Eric Schmidt, former Google CEO and currently chair of the US Department of Defense, Defense Innovation Advisory board, Robert Soros, son of billionaire investor and philanthropist George Soros, and others. Both Emerson Collective and New America represent powerful, billionaire-directed organizations guiding the discourse of young, ambitious journalists like Ms. Engelhart who are willing to promote the neoliberal agenda of market-oriented reforms, privatization and austerity by not questioning the existing neoliberal capitalist system she is writing about.

However, the pandemic has nakedly revealed the failure of the US Government and the private institutions that it depends on to address the spread of COVID in nursing homes. Ms. Engelhart had no choice but to describe in some detail the failure of the nursing home industry to deal with the pandemic. The Kirkland nursing home, from it’s outbreak in February, 2020 to the stabilization of the facility in April, had forty-six COVID-related deaths.

But Ms. Engelhart’s article does not begin with an exemplary presentation of the systemic failure of the government and the privately run facilities that led to the forty-six deaths at Kirkland’s LifeCare facility, but rather cutely, with the stories of two residents, Helen and Twilla and their daughters: slick, vibrating, interpolating artwork sentimentalizes life and loss in the facility, drawing us into the experience of the two residents and away from the forty-six residents and staff that have died. Helen has a world map above her bed “so that [the poorly paid] nurses could point to the countries where they were from” and talk about their former lives in their countries of origin. So the foreign labor that the facility relies on and underpays makes Helen’s life there more interesting.

At this point, Engelhart turns to the negatives: the spread of the virus in the facility, the staff shortages due to illness, including the facility’s medical doctor who was eventually replaced by hard-working LifeCare nurse, Chelsea, who volunteers to take a job there, comparing the job to her combat medic husband’s lengthy deployments, thinking “it would be her turn to go to war”. More residents get sick and Chelsea does do heroic work to try to manage the crisis. Twilla has succumbed to the virus and now Helen seems to be getting sick. At this point, the action stops and Ms. Engelhart abruptly switches to a brief history of the nursing home industry. We learn about how the nursing home industry grew from small, independent, for-profit and often poorly run rest homes, to it’s current domination by corporate ownership that has succeeded in reaping huge profits in a $100 billion dollar Medicaid-subsidized industry. We also learn that state and federal regulations and lawsuits for negligence are hard to enforce when equity firms buy up 75% of nursing homes and restructure them to incorporate related third parties that siphon off profits by billing the nursing homes themselves. Engelhart turns to the expert, Ernest Tosh, a plaintiff lawyer, to learn that LifeCare has followed these restructuring “trends” of the nursing home industry, that LifeCare nursing homes are quite profitable and that the industry’s lobbyists are seeking higher Medicaid reimbursement rates due to “financial distress”.

One would expect Ms. Engelhart to then go on to place the specific predaceous practices and failures of LifeCare within the general predatory practices and failures of the for-profit health care system. Instead, we abruptly return, with a slickly illustrated brushstroke across the page to Helen, lying in bed reflecting on the death of her roommate Twilla, and to hero-nurse Chelsea’s ongoing challenges, moving away from systemic failure and toward personal courage and tragedy -- toward neoliberalism’s comfort zone: identity politics.

Our last image in Ms. Engelhart’s article is that of resident, Helen, isolated from her daughter as they continue visits limited to waving at each other through the window. The writer leaves us with this thought:

        “This part of the story (isolation) is bigger than nursing homes -- bigger, even, than medicine --and maybe most clearly encapsulated in that refrain from the earliest days of the outbreak: It only affects old people. Decades from now, will we be haunted by that “only”?.”

The appeal is toward sympathy for the elderly, who deserve our respect since we will all be old one day. That is the problem! Forget about nursing homes and apparently broken systems. They are what they are and we might as well just get used to it. Katie Engelhart has now come full circle in reducing a dismissed social problem, that she has exposed, to “ageism” that can be combatted individually by Ayn Rand-type heroic individuals: Helen, the rugged individualist from Minnesota who survives the virus at age 98; her demented roommate, Twilla, who doesn’t, but whose selfish daughter hires a selfish lawyer to sue the nursing home corporation for its negligence for big bucks; an emergency medical response team (hired by the State Department and based in Dubai according to my background search) and coordinated by nurse warrior, Chelsea, who ends up testifying in defense of the nursing home corporation when they appealed the fines for their failings.

By the article’s end, we have forgotten the 46 people who have died and the fact that nothing systemic has fundamentally changed to prevent another COVID outbreak in Kirkland or anywhere else. Our attention is now on a political ideology that values the competitive individual over the social and the profit of the corporate person over the needs of society.

This article and others like it must be read with extreme caution. They only serve to preserve the status quo, which has been exposed by the COVID-19 pandemic as unable and unwilling to address the social, economic, ecological and other crises it has itself created.

To sum up, while ageism is a legitimate cultural issue, it should not be used to avoid confronting the failing capitalist system that it is embedded in. Geriatric medicine, academic Gerontology, Aging Studies, and programs focussed on health disparities, relating patterns of death and disease to the political, economic and social structures of society, can help by breaking out of the limitations of capitalist discourse and outline steps towards socialized medicine and a nationalized system of nursing home care. 

Neoliberal media will not permit this discussion.

https://story.californiasunday.com/covid-life-care-center-kirkland-washington

                                                                     

       

Is Critical Gerontology Getting More Critical?

Is Critical Gerontology Getting More Critical?  

Thoughts on a recent article from The Gerontologist

Immanuel Wallerstein, (1930 - 2019) American sociologist and economic historian,  in a recently published 1981 interview, talks about liberal social sciences and the need to reinvigorate Marxist thinking.

 "... the whole problem of development has to be reformulated as the development of the whole unit. This brings considerable changes: for instance, instead of nations, classes, social strata, and domestic units existing per se, perhaps in some sense being linked among themselves, they are now conceived as structures that have developed in the course of the historical development of the capitalist world-economy. These continually change and have to be explained on the basis of the capitalist process, rather than the other way around."  

His world-systems view began to place social science in a global arena, no longer making it possible to rely on the old liberal version of social science, inherited from the 1950's.  This quote seemed particularly fitting for a piece I wrote in August 2019 in response to a 2019 article in the Gerontologist, the generally liberal journal of the Gerontological Society of America.  Of course, much has changed again as we experience the COVID 19 pandemic.  However, this piece preceded that.

__________________

Critical approaches to aging and long term care that present a social structural view of aging are showing up more in academic journals and textbooks though sometimes without clear connection to any specific critical gerontological theory.  Instead, they describe concerns with "neoliberalism" or "corporate control" with little discussion of what those terms actually mean.  Such critiques often conclude with calls to action by "champions of the Long Term Care Aging Network" as in the article discussed below.

My generation was the last to have the luxury of sitting back and studying problems, handing the critical results of our investigations to "champions" and "policy makers" who really couldn't, and still can't, act outside of the system they are embedded in, just as I was during my working years.  While working for public programs serving a growing aging population I was aware of the limitations of these programs, limitations reflected in fears I often had of losing my job due to budget cuts and reorganization.  Today, I question the ability of "champions and policy makers" to adequately improve eldercare within what seems to be a failed system that they serve.  My approach to critical gerontology is based on the experience of having lived and worked during the period when austerity policies gutted public programs in the 80's, 90's, and early 2000's which in turn led me to a desire to understand the capitalist system that created the conditions of my working life.

Nevertheless, I was happy to see in the April, 2019 issue of The Gerontologist (Gerontology Society of America) the article by Polivka and Luo, "Neoliberal Long-Term Care:  From Community to Corporate Control".  The article focuses on studies that examine the effects of taking public money (Medicaid mostly) from publicly funded nonprofit long term care providers and giving it to private for-profit providers administered by large insurance companies which are replacing the nonprofits.

The authors argue that studies clearly show that this for-profit corporate model, embraced by both the Republican and Democrat parties, is neither cheaper nor does it provide better care than the public models they replace.  To illustrate their point, they discuss four evaluation studies of a Florida Nursing Home Diversion Program which in fact reveal that the program's existing community-based, publicly funded nonprofit providers' costs were actually lower than private corporate HMO's, even if health outcomes for both were comparable.  Yet, in spite of evidence given to Florida policymakers from these evaluations-- demonstrating that corporate managed care would tend to be more costly-- Florida proceeded with the conversion of nonprofit public and NGO programs to corporate managed care, aided by legislation passed in 2011 and approved by the Federal Centers for Medicaid and Medicare Services.

The authors also focus on the privatization process of the successful national demonstration project, Programs for All Inclusive Care for the Elderly (PACE).  For 25 years, PACE has successfully provided community-based nursing home diversion services through the Medicare and Medicaid programs.  In 2015, Federal legislation was passed that allows various PACE services in different states to be operated by private health care corporations.

The authors argue that this "movement" towards privatization of Long Term Care, in spite of evidence that it is more costly, reflects a "neoliberal ideology", which they define as the belief that free markets provide goods and services to the public more efficiently than the government.  They outline six political and practical "tendencies" that show rather convincingly (but guardedly) a continuing expansion of corporate-provided care, for profit rather than need, that tends to reduce the quality of care, increase the costs of care, increase reliance on informal care and disconnect services from local community involvement, just as the numbers of older people needing long term care are expanding and informal supports are on the decline.

To combat this trend, the authors call for annual evaluations for both nonprofit and for-profit providers.  Their position seems to be that more evaluations will tend to show that nonprofits provide better care at a lower cost than corporate health care providers.  Along with better lobbying from advocacy groups, these evaluations, they argue, will bring about a return to the public and nonprofit aging network of service providers.

It is interesting and encouraging that careerists and staid academic journals are increasingly willing to publish articles that infer that capitalism's profit-driven drive to privatize everything may be the underlying, systemic cause of the privatization of Long Term Care services.  As cautious as they are, articles like this are a sign of dire times.

As the authors point out, the use of formal academic studies as a channel of influence with policy makers made no difference in the political outcome for two well-established nursing home diversion programs.  Therefore, it is necessary to understand the broader connections at play under neoliberal policies.

A good place to start might be Colin Leys excellent work, Market Driven Politics: Neoliberal Democracy and the Public Interest.  Here he defines neoliberalism as "...market-driven politics... (or)...the political dimension of the shift of power from voters to capital that results from trans-border capital mobility".  This shift in political power relations is characterized by Karl Polanyi as "market society", a social order in which privatization of all social relations has escaped political control.  It is important to understand that the neoliberal program of absolute capitalism is both global and local.  Again, Leys:  "Bringing out the connections between seemingly (though not really) remote market forces and the changes occurring in people's everyday lives is harder work than it was when a great deal of effective power over the economy still rested with governments".  His book examines the process of privatization of two UK institutions, BBC and NHS, to illustrate the workings of a "market society".

In the case of the nationwide PACE program, I looked into the neoliberal processes which display these market forces at work.  In 2015, the Federal Centers for Medicare Services (CMS) hired a private consultant, Mathematica, to conduct a feasibility study for enabling private investment and management of PACE, a program designed to be managed by community-based non-profits. Not surprisingly, the CMS PACE study results showed for-profit management of PACE would not compromise the program which was was successfully managed by community-based non-profits for the 25 years of the program up to that point.  Mathematica, interestingly, was previously enlisted to do a similar study in order to promote Teach for America, the training arm of the nationwide school privatization movement.  Here you can see how neoliberal ideology has influenced "democratic" government institutions, private think tanks, and private media, working hand in hand in the privatization process.  The study results ended up in Bloomberg global media's Health Law Reporter, officially inviting and encouraging private investment in PACE's Medicaid and Medicare funded program:

"Thus, given the need for capital and the infrastructure to be a successful program, there currently is no policy reason to continue excluding for-profit entities from participating.  The goal of the PACE program and other similar programs is to provide much-needed services to chronically ill individuals who might otherwise be unable to receive them.  The inclusion of for-profit organizations in state PACE programs will only increase such access to care.  A positive, uniform state-level approach to for-profit entry to PACE would greatly enhance the program overall.  Thus, the states participating in the program may be well advised to follow Colorado's lead and welcome the participation of for-profit entities by amending the applicable statutes and regulations to reflect the CMS findings and current approach."

The authors of "Neoliberal Long Term Care" seem to be saying that PACE's privatization happened because neoliberal lobbyists were more successful than lobbyists advocating for the nonprofit Aging Network (champions).  Unfortunately, even if aggressive lobbying efforts could preserve or rescue the non-profits,  Older Americans Act (OAA) programs and Medicare and Medicaid-funded services, which make up the majority of publicly funded services for older people, are not enough to cover the care of a growing older population.  That is not to say that private interests should take over.  Through my work in OAA programs and senior housing from the 1980's onward, and as a caregiver for parents with dementia, I have seen the shortfall in services over the decades and experienced  favoritism for private-paying nursing home residents over those relying on Medicaid.   Rather than developing a strong, national socialized system to care for the elderly, the Federal policy towards eldercare has always been one of piecemeal programs and questionable "public-private partnerships".  It's just worse now.

We are at an interesting conjunction of having reached the predicted demographics of a large older population worldwide and the crisis of global capitalism, which has its roots in the decades-old falling rate of profitability under capitalism.  The falling rate of profitability is behind the neoliberal policy of privatization, seeking new profits from services addressing the most basic human needs such as health care, education, food security, and housing.  The government under both Democrats and Republicans alike are working within this ideology.  Neoliberal austerity measures and privatization of public services can't be lobbied out of existence.  Under capitalism there is often a "contradiction between the pursuit of health and the pursuit of profit." (Lesley Doyal, The Political Economy of Health, Pluto Press 1979, p.44).  Although 19th century advances in medicine improved standards of health as measured by life expectancy and mortality rates,  delivery of health care under capitalism will always end up doing harm simply because of its profit-driven (not health or social-driven) nature.  Again, from Lesley Doyle, "while we cannot specify in advance a utopian blueprint for a socialist health policy, we can assume that under socialism profit would no longer be the criterion for making decisions about production or consumption"... and "that a real concern for the population would be reflected in planning and decision making." (Doyal, p.22) We need to be studying how to transition to socialized medicine, away from government underwriting of for-profit "healthcare", and away from having to piece together non-profit community services to meet the huge healthcare needs of frail elders.

Critical structural approaches to Gerontology were not discussed in graduate programs or practical settings.  Many of us have spent years advocating for better eldercare yet we have all been victims of an entrenched liberal ideology, now called neoliberalsm, that imposes market-driven policy.  However, younger academics and practitioners are recognizing this dilemma and are confronting and challenging capitalism itself.  Their precarious future is different from our comfortably precarious present.

How can established Gerontologists join forces with younger, radical academics and activists in multiple disciplines who are making important connections between the current state of health care and its historical, political and economic context, often using a Marxist approach?  Critical Gerontologists can begin to connect with the emerging socialist and pro-labor healthcare movements to make sure that the needs of the aging population are understood and included in any discussion or action (Medicare for All, Health over Profit, Physicians for National Health Care, National Nurses United) to name a few.  We need to be the voice for the older population among the younger and class-based socialist movements, (DSA, Greens, Poor Peoples Campaign, Working Families Party, etc.) to counteract the privatizers' efforts to pit the generations against each other, just as identity politics separates people into factions based on gender, ethnicity, color.  We need a collective push away from capitalism and towards a true socialist project, through education and study, practice and speaking out in order to move beyond politics as we have known it.  In the meantime, we can acknowledge the willingness and moral imperative to begin to name and understand the current conditions that affect long term care, as Polivka and Luo have done by describing destructive neoliberal-based policies, while also recognizing that politics as usual is not enough to address the long term care needs of a growing older population.