The Media Narrative

Every article about problems in nursing homes in America is the same. It’s the same across news outlets and the same across the decades. You’ve read it dozens of times, and you will read it dozens more.

The main image is of a dour-looking person, typically standing in a yard or living room just like yours, holding a photo of an older person. The composition of the shot immediately tells you the person in the photo-within-a-photo has died, and not peacefully. The story will begin with graphic details about poor care, abuse, or neglect – perhaps the person in the photo was raped, or had bedsores so ignored that maggots began feeding on their flesh, or languished for hours or days in soiled undergarments without food.

The loved one holding the photo will tell a truly heartbreaking story of how their mother or father was mistreated, how the human being who created them and served as the anchor of their entire life died in filth and disrespect. The photo-holder’s personal injury lawyer will provide a fiery quote about the inhuman conditions at the facility; the reporter will helpfully fill in evidence of past fines and enforcement actions at the facility that did not prevent this person’s fate. The operator of the facility, either directly or through their own lawyer, will offer a milquetoast statement about how the care at ABC Health & Rehabilitation is top-notch, and while they can’t comment on this case due to ongoing litigation, they offer their condolences to the family.

Then the story zooms out for a national perspective. A few usual suspects from the world of vocal nursing home reform advocacy will give even more fire-and-brimstone quotes about the heartless nursing home lobby that cares only about profits at the expense of frail and vulnerable human lives. Their prescription will invariably be higher fines and the unfettered ability to sue nursing home operators. Only through the threat of being financially punished into non-existence, they argue, will providers proactively improve care.

The reporter will dutifully allow a representative from the lobby to respond. Most likely, this will be someone from either the national American Health Care Association or one of its state affiliates, and the message will always be the same: We need more money. Medicaid, which covers long-term care services in America, does not pay enough per resident per day to cover the cost of their care, so really, the federal and state governments are getting what they pay for. The truly nefarious behavior, like outright fraud and criminal neglect, is merely the work of bad apples. Fines and lawsuits, meanwhile, only further damage nursing home operators’ financial health and force the good apples out of the business.

The advocates will respond: Ah, the industry says that Medicaid rates aren’t enough, but how do you explain the rich nursing home moguls, the multi-million-dollar price tags for nursing home real estate, the lavish spending on lobbyists and high-priced law firms? Owners and operators hide behind a complex web of shell companies, and we have no earthly idea what their finances actually look like, but all the circumstantial evidence points to a lucrative business built on terrible outcomes.

Here’s where the foundational structure of journalism fails to capture the problem. There’s truth, albeit in varying amounts, in what all these players say in all these articles. We do not face a choice between increased fines or increased funding. We do not have to do what one group says at the expense of the other.

We can admit that a for-profit health care system will always incentivize cost cutting, and that $150 per day in Medicaid funding is not enough to spark new investment in better eldercare communities under a for-profit health care system, and that providers have skillfully obfuscated their true financial health, and that there should be financial consequences for poor care, and that going after individual homes with fines and lawsuits will not transform the sector overnight, and that the for-profit nursing home industry is more of a complex real estate ecosystem than a health care system, and so on ad infinitum.

But that’s way too much to explain in a 700-word story about a truly terrible event, and it doesn’t give readers a clear hero to cheer and a clear villain to curse.

Journalism: not at all like All the President's Men

I studied journalism in college in large part because I always liked to write, but also because I wanted to have something more marketable than an English degree after graduation. I wasn’t even halfway through my freshman year when I realized that I wasn’t cut out for the work: I hate calling strangers on the phone, constant deadlines don’t help with my already high base-level anxiety, and I can be thin-skinned and combative in the face of criticism (I am from Long Island, after all).

I stuck with it because I was too young to have learned the sunk-cost fallacy, and I managed to last about 18 total months in low-level reporting positions before I jumped ship to newspaper layout and eventually a role editing appraisal reports for a small financial company.

I only returned to the semi-journalistic world of trade reporting because I knew it was generally easier than being a general assignment reporter at the Podunk Weekly Dispatch, and I gained enough knowledge in school and on the job to take care of the icky parts – talking to strangers, asking uncomfortable questions, feeding the insatiable, gaping maw of content week after week – as quickly and efficiently as possible.

Part of that is figuring out who will talk to you and who won’t. It’s a skill that any reporter learns to master above all others: If you’ve got a topic you don’t know a ton about, and an editor breathing down your neck for copy, you’re not going to mess around finding new sources to give you splashy quotes.

So you Google other articles about nursing home reform. Quickly you realize that you keep seeing the same credentialed names giving really juicy quotes. You call them up and get similarly juicy quotes for your story so you can file the piece and move onto the next five things on your plate.

You do not necessarily follow up on the piece past the initial outrage. You do not dive into the endless PDF reports from experts and working groups, laying out the detailed and heavily studied solutions that have been developed and promoted for decades. You do not take the time to talk to multiple residents, caregivers, social workers, and other folks on the ground about what they want.

I didn't even last two full years in "real" newspaper journalism and I wrote stories the exact same way on topics as varied as fire safety, Icelandic country singers, and corporate wage theft. To this day I don't know anything more than the average person about those topics, but I cobbled together enough facts and interesting perspective from experts to meet my deadline and go home.

The four or five people who are quoted in most nursing home reform stories – including Harvard’s David Grabowski, a fair-minded and nuanced voice generally invited in as something of a neutral, academic arbiter between the warring sides of reformers versus lobbyists – are not the only four or five people in the country who have valid ideas about nursing home reform. They are simply the people who have made themselves available for public comment. For a relatively niche issue like nursing home reform, it’s pretty easy to turn yourself into one of America’s foremost experts on the issue: Just keep picking up the phone whenever reporters call and saying eye-catching stuff in short, pithy sentences.

And reporters will keep calling, and they will keep considering their stories complete when they’ve gotten quotes from “both sides,” even if those two sides are just lawyers on opposite sides of the for-profit industry, with a single academic thrown in for balance.

Man bites dog

I can’t begin to tell you how many times I heard some variation on this quote from nursing home execs when I was at Skilled Nursing News: “Why don’t reporters ever write about the good stuff that we do? Why are they always out to get us?” And I would always have to respond: That’s because it’s not news.

As I hope I’ve illustrated, it’s true that the media narrative around nursing homes can be woefully incomplete and severely undercooked – but it’s just not news for a business to provide the service that the government pays it to provide. It’s not even news when that business goes above and beyond its mandate to provide exceptional care.

It’s not news when the flight arrives 10 minutes ahead of schedule, but it is news when that flight arrives 10 minutes ahead of schedule by crashing into the terminal and killing hundreds.

You’ll never stop the media from reporting on the bad stuff that happens every day in U.S. nursing homes, as they should. But you can try to prod the media and policymakers into expanding their perception of the nursing home landscape writ large – including the fact that the real moneymakers in the sector aren’t at all interested in health care. They’re just real estate investors who know a stable asset when they see one.

Next up, we dive into the real estate dollars that truly drive the industry's direction in Episode 2: Sticks and Bricks.