By Jack Cumming

Recently, Steve Moran, Publisher of Senior Living Foresight, wrote in two articles titled, “I Want to Cry” (Part 1, Part 2) of his father’s experience as a new arrival in a nursing home. Steve writes, “Since being admitted to his nursing home, his sense of isolation and lack of stimulation is making him feel like he is rapidly losing cognitive ability. Perhaps like when you walk off a 5- or 6-hour flight and everything seems not quite right for a few minutes.”

Better Dead Than in That Bed

We can all relate to that. If you’ve ever been in a conventional nursing home, you know that it’s no place you want to spend time, especially with a stranger roommate. This is not a new challenge. It is a complicated one, not only because of persistent convention but also because of the heavy involvement of the federal government. For the past thirty years, though, an idealistic physician, Dr. Bill Thomas, and his wife, Jude, have dedicated their lives to lifting the lives of nursing home residents. It’s time to make their mission national policy.

In the early 1990s, while working as a young emergency room physician, Dr. Thomas took a side job at a nearby nursing home. It wasn’t long before he felt a calling to change the experience of those he was tending. He observed that the residents were plagued by loneliness, helplessness, and boredom, which he calls the three plagues of eldercare. These are the same plagues that Steve’s father is encountering all these years later. That ought not to be.


We mentioned the federal government, so let’s segue to the Federal Centers for Medicare and Medicaid (CMS) which determines reimbursement patterns for many nursing home residents. Medicaid is the primary payer for nursing homes, covering more than 60 percent of all nursing home residents and approximately 50 percent of costs for all long-term care services. Those Medicaid residents can be people who worked minimum wage jobs all their lives and were left indigent when they could work no longer, or they may be affluent people drained of their assets by care costs. In either case, they ought not to be deprived of their dignity merely because they are old and may be seen by some as expendable.

Moreover, Medicaid reimbursements only cover 70 to 80 percent of the actual cost of nursing home care. This chronic gap in funding has resulted in shoestring budgets and ongoing operating losses for nursing home providers. Think about that. It may be that CMS is seeking to rein in America’s outsized healthcare expenditure by under-reimbursing nursing home confinements. The result though is to perpetuate the three plagues of loneliness, helplessness, and boredom that the Thomas’s Eden Alternative movement has long sought to counter.

Political Failure

We could hope for a change in national policy that would suddenly allow nursing homes to be what we might like them to be. That seems unlikely to occur. It’s too easy politically to discount the worth of people who are nearing the end of their days. It’s not surprising that many older people would rather die than be sent to a nursing home.

You may have heard that some CCRCs are closing their skilled nursing sections. This possibility is resulting in pushback from many CCRC residents who are counting on lifetime care on their home campus with their spouses and friends nearby. Ann MacKay, the president of the Maryland Continuing Care Residents Association, recently directed my attention to a July 2019 LeadingAge report titled, “Right-Sizing Nursing Care Settings in a Life Plan Community.”

In the absence of policy changes to make federally regulated nursing centers more homelike and humane, the ethical course is for senior living operators to beef up high acuity assisted living so that the services needed by the very frail – two-person transfers, infusion therapy, 24-hour RN on duty, etc. – can be delivered in a more acceptable setting.

Medicaid should not be driving our nursing care to be substandard. If we put in place the kind of care people need in a setting that doesn’t rob them of their dignity and their humanity, then Medicaid will have to adapt. Already, there are waiver programs that allow some Medicaid patients to escape the high cost of confinement in the sterility of a nursing home medical facility.

Shortening Lives Is Not the Solution

As long as mandated reimbursements are below cost, we have to expect the kind of triple plagues which Dr. Thomas delineated and with which Steve’s father is now forced to grapple. The indigent for whom Medicaid is intended are not people who can make up reimbursement shortfalls out of personal funds. It’s not surprising that people would prefer death to the nursing home alternative unless, like Steve’s father, they expect the ordeal to be short-term.

According to mythology, in ancient times Eskimos would assist the elderly to die rather than have them take food and other scarce resources from the productive community. We ought not now, in our affluence, to feel a compulsion to deprive the elderly of life merely to save money.

If regulations now prevent nursing homes from being the havens that people should have for their years of decline, by all means, let’s accelerate their closure, to allow better life-enriching options to thrive.