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Deregulation Part 3: Government-simulated accountability abandons Idaho’s elderly

Deregulation Part 3: Government-simulated accountability abandons Idaho’s elderly

Niklas Kleinworth
July 27, 2023

Nursing homes are among the most heavily regulated health care settings. With approximately 900 pages of federal and state regulations in place, virtually every aspect of these facilities is controlled by the government. Despite this, Idaho’s facilities fail to meet the needs of their residents.

Nursing homes are an example of how Americans — in our promotion of convenience — invite government control and regulations at the expense of liberty. In this final part of our series on deregulation, we see how government intervention is a poor substitute for personal agency and the free market. Regulatory reform may be useful, but only a substantial culture shift will end the destructive outsourcing of personal responsibility to bureaucrats.

Idaho’s nursing homes are in a sorry state of affairs. The average facility garners a score of 3.5 on a 5-point scale established by the Centers for Medicare and Medicaid Services. Federal inspectors found over 96% of all facilities had violations related to infection control and more than one-third had “serious deficiencies” in quality. 

Facilities face huge costs for violating government standards. Three in five accumulated more than $5,000 in fines in the last three years — totaling more than $2.8 million statewide. CMS even suspended payments for more than one-third of Idaho’s facilities due to the number and severity of their violations. Under federal law, this means that about 60% of Idaho’s long-term care facilities cannot train new professionals like nursing assistants due to the number and severity of their fines.

Statistics cannot express the human cost of substandard care. When a facility violates infection-control standards, that could result in sicker patients. This often leads to more visits to the hospital, lower quality of life and more costly treatments. Families are harmed by the additional financial, emotional and logistical costs of treating these infections, and they are sometimes torn apart by the tragic loss of a loved one in a place they trusted to provide care.

Regulations on nursing homes multiplied and expanded in scope for the last 60 years, yet there are still signs that the care homes provide is insufficient, leading to worse outcomes for these residents. Some studies argued that more regulation improved the quality of care. But they also conceded that the market was a larger contributor to improvements in things such as staffing levels and spending on non-medical amenities.

Recently, the government has tried to build on market forces by rating nursing homes 一 theoretically, enabling consumers to make more informed choices. CMS’s rating metrics, however, have done little to improve quality — through market forces or top-down controls. The CMS rating system is also prone to abuse and rating inflation by virtue of self-reported metrics, diluting its usefulness.

Idaho has its own system, built on some of the metrics CMS uses. These metrics focus on patient outcomes, namely indicators of worsening conditions or abuse. Nursing homes get paid through Medicaid, and their payment depends on how they score and how they improve over time. This is a pseudo-market approach that tries to force a government program to mimic consumer behavior 一 albeit, unnaturally.

The problem with this rating system is that it focuses on scores more than quality. Idaho’s current rating system pays no attention to whether or how nursing home residents reach the goals outlined in their care plan, or their quality of life. In short, it ignores some of the most important components of well-being.

The focus of patient care should be redirected toward each person’s health care goals. This requires examining how professionals are maintaining their standard of care, rather than regulating every minutia of the nursing home environment and experience. 

Regulators fixate on measuring certain aspects of a nursing home, such as the minimum size of windows and the number of hours an administrator can work in a week, that are not as key to ensuring that residents are meeting their goals. Yes, it is important that a patient does not get put in a room without any sunlight and facilities have proper supervision. But what is outlined in the Idaho Administrative Code is not necessarily the best way to run a business or approach the patient’s care. Many would agree that neglecting residents and leaving them in dark back rooms does not lend to the proper standard of care and would be evident in the patient’s health outcomes. Ensuring that a window is “at least one-eighth of the floor area,” however, does not necessarily promote wellbeing.

Who is best equipped to ensure nursing home residents are reaching their health care goals?

Despite the temptation to say that the government should get involved in measuring and enforcing how these residents are treated, such an approach is far from the solution. Stopping runaway regulations requires a cultural change in America. We need to stop outsourcing our personal agency for the convenience of having our lives centrally planned by bureaucrats.

Nursing homes have been coopted by the government to provide a superficial resemblance of the accountability that the free market should be providing. Many nursing home residents cannot advocate for their own care but are subject to a culture that considers people, relationships, and lives disposable. Thousands of Idaho’s nursing home residents have no contact with the family, advocates, and loved ones that put them there for their care. A simple visit by a family member or friend would do more to notice and root out mistreatment than a government rating system. 

It is time we as Idahoans embody the Idaho values of caring for our family, friends, and neighbors by taking back our role as the sole source of accountability. If nursing home residents are being mistreated and their health is declining, someone who visits and has a personal concern might notice and demand action. The market could, then, begin to improve the system as people seek better options. In the meantime, thousands of Idaho residents are forgotten as we outsource our advocacy for them to the government.

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