“Fifty-six nursing homes have closed in the last two years, one every other week. The situation is finally getting people’s attention.”

These are the words of Scott Plumb, Senior Vice President of the Massachusetts Extended Care Federation, who attributes the problem to unrealistically low Medicaid rates paid by the state.

Plumb recently authored a report entitled “Where will your mother go?” detailing what is happening to Massachusetts’ nursing home industry. His agency sees another fifty homes closing before New Year’s Day of 2003.

“That may be true but can’t we go back and ask people what they want?”  This is what Al Norman, Director of Massachusetts Home Care, says of the nursing home crisis.

Norman quarrels with the assumptions behind the title “Where will my mother go?” In his view, mother should not have to go anywhere, if she wants to stay at home, as most older people do, and funds are available to make that possible. He also remains skeptical about the poor-mouth claims of the nursing homes industry.

The clash between the views of these two professionals signals issues of prime importance for elder residents of Massachusetts. What will this state’s leaders do about nursing homes? Will these decision makers shift long-term care emphasis toward home care services and fund enough such services to keep elders out of institutions?

The fate of proposed legislation called “Equal Choice” will give a strong indication about which direction the Commonwealth will take. This Equal Choice bill has been introduced by Senator Brian Joyce and Representative Mike Festa, both of whom see it as responding to what elders themselves want.

In a press release, Festa and Joyce regret that “the level of compassionate choices provided to our seniors is sorely lacking.” They cite the startling disparity in the amounts the state pays for home care compared to institutional care. “Medicaid pays $130 a day for nursing home care, while home and community programs are based on a payment of $7.38 a day.”

In a telephone interview, Senator Joyce told me how his concern started with his mother who has Parkinson’s disease and now lives in a nursing home. “If not for these angels of mercy, the home care workers, my mother would have ended up in a nursing home sooner than she did.”

Not surprisingly, given this experience with his mother, the senator says he does not want to pit nursing homes against home care, but only to give people a choice. In this spirit he makes the following pledge to older people: “We will spend as much to keep you at home as we are willing to spend to keep you in a nursing home.”

Al Norman takes Oregon as a model of enlightened priority shifting. That state now spends more on home care for elders than it does for nursing homes. He also thinks that Massachusetts must respond to the decision of the United States Supreme Court in the 1999 Olmstead case.

That decision interpreted the Americans with Disabilities Act as requiring states to give people who are eligible for nursing homes the option of remaining in the community. That, of course, requires public home care funds for those with incomes too low to afford to pay privately.

But Scott Plumb insists that the financial plight of nursing homes is close to desperate. The situation has been building for years: in 1999 alone, these facilities in Massachusetts lost 72.2 million dollars and the Commonwealth ranked third state from the bottom in average nursing home profit margins. Currently, one in four nursing homes is in bankruptcy, though most of them remain open.

Of every ten residents, eight are supported by public funds. Very few of these funds are provided by Medicare; almost all come from Medicaid, a program shared by the federal and state governments. Because Medicaid payments made by the state remain so inadequate, the availability of qualified staff members and the likelihood of their staying on the job have been severely compromised.

My own view includes sympathy for both positions. At this time, the state simply cannot allow nursing homes to keep closing until there are none left. After all, there will always be some people for whom home care is not a realistic option. To be responsible, our society must support some institutional care for these people, care that respects their dignity and individual needs.

To determine what the financial needs of the industry actually are, perhaps the state should appoint a commission to look at nursing homes as objectively as possible.

I also support the shifting of priorities toward home care. The current disparity of funding makes very little sense. Home care should come first and become the norm; institutional care is certainly needed but remains secondary. And our society should demand that both kinds of long-term care be a whole lot better than they are now.

Richard Griffin