HoW Will We Pay for it?

It's been said so many times by so many people with so many different flavors of politics — from socialists to liberals to libertarians to budget-hawk centrists to principled doves to high schoolers just starting to form their view of the world — that it's lost a lot of its rhetorical punch. But that doesn't make it any less true, and so I'll say it: Why do Serious Policy Folks fret about the cost of programs or initiatives that might actually make people's lives better, but cheerlead the burning of trillions on wars and corporate tax breaks?

My teenage years coincided with the beginning of the War on Terror, America's most recent imperial boondoggle, and so I will always be a proponent of this argument no matter how cliched or trite it becomes. You simply cannot use the "how are we going to pay for it?" argument on me regarding any positive social program, because I saw trillions spent on wars that nearly everyone now agrees were based on nothing more than hot air.

And it's still true 20 years later: Nobody clutches their pearls and asks us to please, please think of the children's future we're mortgaging to pay for more tanks and drones and ammunition and military bases. The check's already in the mail before there's a chance for debate.

My views on geopolitics and American empire aside, "how are we going to pay for it?" is the comforting final refuge of people who benefit from the status quo and want to shut down any progress toward a better world. It's an instant conversation-ender that, in the eyes of far too many people, simultaneously positions the speaker as a clear-eyed and rational actor unmoved by wavy-gravy idealism.

The problem with this argument, particularly as it relates to our nation's nursing homes, is that it's based on a false choice. Much like we do not face a mutually exclusive decision between increasing nursing home funding and tightening oversight, we do not face an either-or proposition between expensive alternatives and a free (or even low-cost) current system.

Every year, U.S. taxpayers spend hundreds of billions of dollars on nursing home care that, on the macro scale, just about everyone agrees is sub-optimal at best and harmful at worst. In 2020, admittedly a more expensive year for all health care providers, the total tab was $196.8 billion. (If you're wondering, the last pre-pandemic year saw a nursing home bill of $174.2 billion, notably less but still a spicy meatball.)

We will spend even more billions on nursing home care in the years to come, as the baby-boom generation continues to age into the need for these services. And yet nobody outside of a small minority of balanced-budget obsessives asks how we'll pay for it. Like the weather or the tides or another $700 billion for the military, this spending just happens, and it will continue to happen for as long as the federal government keeps running Medicare and Medicaid.

To be sure, institutional inertia contributes heavily to this dynamic — from giant government systems to cubicles in drab offices across the world, "this is how we've always done it" is a powerful drug. But it doesn't provide a full explanation.

Allowing elders to die before their time due to preventable illness, hunger, homelessness, and the other byproducts of poverty was how we always did it until Medicare, Medicaid, and Social Security came along. Physically tying people to beds to "protect" them from falling or "escaping" nursing homes was how we always did it until the Untie the Elderly movement revealed the horrors of physical restraints to lawmakers. Forcing people into nursing homes as the only eldercare option covered by Medicare and Medicaid was how we always did it until assisted living, home health, PACE, and other community options built out a fuller continuum.

Aside from the notion of right and wrong, there's another sneaky common denominator that explains the shift: cash. The Great Society made eldercare profitable by covering senior-specific services, and so nursing homes went up across the country to meet the demand and capture the federal largesse.

Physically restraining elders became illegal under the sweeping federal reform package commonly known as OBRA '87, and while it still occurs (and while resident advocates make fair points about the toothlessness of regulatory enforcement), the threat of fines led to a steady decline in the use of physical restraints.

Medicare, Medicaid, and private insurers now cover a variety of nursing home alternatives, and while that coverage is fragmented and spotty, any given elder in the 2020s now has more options for care than, for instance, my grandfather did when he turned 70 in 1981.

I wasn't around for the exact conversations, but I can guarantee that "how will we pay for it?" was considered a smart and prudent retort to all of those reform proposals. Sure, older folks dying because they have no income post-retirement is bad, but who's going to pay for Social Security and Medicare? Sure, tying elders to beds isn't optimal, but who's going to pay for the extra staff we need to keep them safe otherwise? Sure, many older people require additional supports but not around-the-clock medical care, but who's going to pay for home health?

Somehow we find the dollars, and somehow the dollars spur investment in new things. Those new things aren't always perfect, but they almost always represent an improvement over what came before — and with the right oversight and transparency rules, we can keep improving these new ways of doing things.

So the next time you hear someone ask "well, how are we going to pay for it?" during a debate about eldercare reform — or any reform, really — try to hear it for what it really is.

It's not the cry of a well-meaning fiscal steward, burning the midnight oil with an adding machine and a green visor as she tries to make the numbers come out right for a nation of hardworking taxpayers.

It's the defensive reaction of someone who's carved out a lucrative niche thinking "how am I going to pay for my lifestyle once this comes along and starts taking away some of my pie?"

The status quo in nursing homes is profitable for everyone involved, from the operators to the landlords to the investors to the vendors who cling like barnacles to the giant ship of government revenue — as well as trial lawyers, the resident advocates that they fund, and the liability insurance companies that protect operators from the trial lawyers in exchange for ever-increasing rates.

This is not meant to be a personal attack on anyone who may see themselves in those categories. As I've written before, everyone is playing a role in a system they did not build and cannot control alone; I wouldn't have my current position if I didn't benefit from my role as an industry-neutral to -friendly trade reporter for nearly five years, and my day job gives me a significant personal incentive to advocate for structural changes to the nursing home landscape.

But especially at a moment where COVID revealed every dark corner of the nursing home world, we have to see resistance to change through the lens of a for-profit health care landscape.

There's no question that the federal government can and will pay for whatever it wants. If we really want to see change in the way this country cares for its elders, we can't keep falling for self-interest disguised as maturity and concern.