The Covid-19 pandemic has energized calls for a drastic solution: closing nursing facilities altogether. This year, Covid-19 has killed around one in every 35 nursing home residents in the United States—over 50,000 people. More than 1000 nursing facility staff members have also died from the disease. Even in the best of times, the industry struggles with quality care because of short-staffing, poor infection control, and abuse and neglect.

Why do we have these facilities where people are not receiving proper care?” said Susan Dooha, the executive director of the Center for Independence of the Disabled, New York. “Maybe we don’t need them.”

Deinstitutionalization is the effort to expand at-home or in-community care options for disabled people in need of long-term care.  In the US, such ambitions have run up against the for-profit nursing home industry funded by billions of dollars of taxpayer funds through Medicare and Medicaid payouts. That industry is tasked with providing care to vulnerable people in the nation. Institutional care is more expensive, and even though many nursing home facilities suffer from what critics say is a well-documented history of problems.

Advocates say problems have only intensified as large corporations began consolidating nursing home franchises. Around 70% of nursing homes in the US are under for-profit ownership, and, since the 2000s, private equity firms have purchased many facilities, hoping to cut costs and increase profits. One recent analysis, published by the New York University Stern School of Business, found “robust evidence” that private equity buyouts were linked to “declines in patient health and compliance with care standards.”

Nursing homes became commonplace in the 20th century, enabled by twin shifts in American life: government aid for the elderly, and medicine that allowed more people to reach an age where they could actually use it. Such facilities began multiplying shortly after the passage of the Social Security Act in the 1930s, and they expanded with the introduction of federal- and state-run health programs like Medicare and Medicaid in the 1960s. Nursing homes are distinguished by their capacity to provide skilled nursing care and, typically, 24-hour support for residents.

In the early 2000s, policymakers began doing more to prioritize home care for people who might otherwise have ended up in a facility. Emphasis was placed on supporting patients who could receive care in their own homes, either from family members or home health aides. A major 2018 survey from AARP, the aging-advocacy organization, reported that close to four in five Americans aged 50 and above prefer to age at home. “Most older people are anxious about the prospect of moving into a nursing home,” a recent analysis of studies in high-income countries reported, and studies consistently show high rates of depression in facilities.

For years before Covid-19, researchers have warned that norovirus, influenza, and other infections can spread rapidly in nursing facilities. Those risks have increased in recent years, as nursing homes take in more short-term residents who are getting rehabilitation after hospital visits, and who potentially bring infections into the building with them, said Lona Mody, who runs the Infection Prevention in Aging Research Group at the University of Michigan Medical School. In addition, Mody said, “staff members’ compliance to hand hygiene in the past has been not good.”

The scale of suffering during the pandemic has led to calls for change. “We’ve created this system, and now we’re telling all the people who work in it to just make it work. And it doesn’t work,” said Sonya Barsness, a gerontology consultant who works on reforming nursing home culture. “This pandemic,” she added, “has brought light to the reality that the system is not adequate to support the needs of people as they grow older.”

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