Brendan W. Williams, M.A., J.D.

An oft-repeated canard that bedevils advocates for facility-based care is the assertion, by an organization that peddles Medicare insurance products, that “90% of people don’t want to be in a nursing home.”

We live in a post-factual world, where even facts are dismissed as “Fake News,” and people consume information through the biased filters of their choice.  But as someone who went through graduate school and writes academically, I have always valued empiricism.  Too often we trade in anecdotes.

What has always struck me about this anti-nursing home canard is what the context of the question would have been to yield its result, assuming there ever really was a question posed. That’s because you would effectively be asking someone if they want to be sick and infirm enough to be in a nursing home. If that is your question, I can’t imagine anyone — let alone 10% of respondents — wanting debility.

Given a choice, I would choose a “Minute Clinic” over an emergency room. But life doesn’t always give us choices. A 2017 RAND Corporation study determined that among those between 57 to 61, over half would spend at least one night in a nursing home during their lifetimes. One can safely assume that those who receive nursing home care are not fulfilling some lifelong aspiration.  

In April 2019, I posed a different question through the Granite State Poll conducted by the University of New Hampshire. It went like this: “Imagine a situation in which you had a physical limitation or dementia that required you to receive assistance with your daily activities. Generally speaking, would you prefer to live in your own home and be cared for on an hourly basis, even if there are times when no caregiver would be present, or would you prefer to live in a long-term care facility and have continuous access to caregivers and social interaction?”

That is an honest question. Not surprisingly, the majority of respondents preferred to be cared for at home. But not 90% — 64%.  Twenty-three percent would choose a facility, while 10% said the answer depends on circumstances.  What I found interesting was that, by age grouping, the highest proportion of those who would flatly choose a facility in the circumstances described were the young — those 18-34. Twenty-eight percent of that group would prefer living in a facility.

In New Hampshire, with the nation’s second-oldest population, long-term care advocates have successfully united over the past couple years and avoided the demagoguery of those who would seek to divide them. Having your long-term care needs met should not be like “Lord of the Flies” and based upon whomever blows the conch shell the loudest. The entire long-term care continuum should be robust, but too many states (including New Hampshire) have saved money by significantly reducing the Medicaid nursing home population without, in turn, investing money in home-and-community-based services.  

Like most states these days, New Hampshire does not have nursing home residents who could be responsibly cared for at home. To hold on to such residents would be self-defeating anyway, as Medicaid payments for nursing homes, already among the nation’s worse in terms of the deficit from allowable costs, are based upon acuity. Thus, although my association represents facility-based care, it has advocated for lifting arbitrary caps on Medicaid payments for HCBS.

More enlightened advocacy would not focus on trashing nursing homes, but on recognizing the interdependence of a fragile long-term care system.  Oregon, for example, leads the nation with the highest proportion of Medicaid for HCBS. It guarantees home care workers a wage of no less than $15 an hour while also providing a nursing home rate over $100 a day higher than New Hampshire’s. 

Oregon, and other states, show it’s possible to honor the entire long-term care continuum without robbing Peter to pay Paul.

Brendan Williams is the president/CEO of the New Hampshire Health Care Association.