A too-cozy relationship

Private nursing homes and state government’s Medicaid agency operate almost as an integrated massive service industry, somewhat unavoidably.

Theirs is among the most symbiotic of government-business relationships. Think of a conveyor belt running round-the-clock between them.

If a poor old sick person gets to the point of requiring residential care—a $6,000-per-month proposition well beyond a Social Security check’s reach or a typical family’s ability to pay—then the state’s Medicaid program pays for the care that the nursing home provides for a profit.

Sometimes there’s an interim step: The resident’s assets, the fruits of a lifetime’s work, are drawn down at the rate of $6,000 or so a month. Then, when a lifetime’s dignity has been reduced to pauper-ism, the state takes over.

Any middle-income Arkansan, no matter how virtuous, no matter how resourceful, no matter how proud, is a prospect for such a fate.

Through it all, one thing is understood: No one is going to leave a poor, sick, penniless grandma out in the cold.

Nursing homes aren’t bad. They are vital. But they vary. I’m fine with my mom’s. I’d say I’m happy with my mom’s, but happy is not the right word for the fate, never mind the facility.

It would be nice if life’s journey didn’t offer desolate poverty and institutionalization as its destination. But this is how we do it.

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The best options to nursing homes—or the soundest incremental pre-nursing home services—are Medicaid-subsidized in-home care and assisted-living care.

Recently the state proposed to cap home care and cut assisted-living care. It did so, as a front-page article in this paper reported Sunday, after a regulation-writing process in which nursing homes were intimately engaged with state officials but in which agencies of in-home care weren’t engaged at all.

Did you get what I just wrote there?

Let me restate: The proposed financial cuts to in-home options to nursing homes that I decried in this space a week ago as counterproductive, absurd and mean … it turns out the nursing home association and state Medicaid people teamed up to design those.

It was business as usual between essentially adjoining offices in an integrated service industry.

But as Herb Sanderson of the Arkansas chapter of AARP put it in the article: Nursing homes were entitled to be invited to a table with regulators. But so were other affected agencies and providers—those affected directly by the new rules, for sure—and, in this case, they weren’t. Scandal? That’s too strong a word for a hardly secret relationship that is unavoidably close. But it still can be too close. Here’s how this regrettable situation came to pass: Gov. Asa Hutchinson wants to cut taxes because that’s all Republicans know to do. He looked around for places to cut spending and decreed that the growth in Medicaid simply had to be curbed.

The nursing home association, with good lobbyists, prevailed on the governor to let it design its own cuts, rather than have them imposed by regulators. The governor … well, he agreed to the special privilege, to keep it all in the corporate family.

Nursing homes have indeed designed reductions on themselves. But it was that special self-regulatory status that put nursing homes at the table with official state regulators on a full array of cost-cutting issues of long-term care including those affecting providers of alternative forms.

As a nursing home association spokesman said in the Sunday article, nursing homes maintain an interest in all levels and forms of care for the elderly. Nursing homes need, the spokesman explained, for the alternative forms to remain vibrant, which they can only do, you see, by sustaining new efficiencies imposed essentially by a bigger and more politically connected competitor.

Or maybe you don’t see. Because I don’t.

The ailing and still-at-home grandma who gets told that her hours of in-home care are being cut from last year, even as her condition has worsened … she has no seat at the table, and, considering that she is in physical and probably cognitive decline, couldn’t get to the table anyway.

But someone ought to argue for her—someone other than the profitmaker to which she and her 401(k) balance probably are doomed.

Alternatives that slow the conveyor belt of this integrated industry—that postpone the costlier inevitable institutionalization of the inevitable pauper—ought to get more consideration, and more clients, and more money, not less.

If anyone should be at the regulators’ table to the exclusive of another … well, I’d say it would be the other way around.

So, in the category of better late than never: The state Human Services Department, under delightful public pressure resulting in tardy but welcomed legislative pressure, retreated this week.

It said it would delay and revisit these proposed cuts. It even announced it would—imagine this— discuss them with home-health and assisted-living providers.

Grandma gets to stay home for one more Christmas, so to speak.