John Oliver on nursing homes and elder care: ‘A strained system pushed to the brink’

John Oliver devoted the main segment of Sunday’s Last Week Tonight to a perennially overlooked healthcare issue in the US: nursing homes and elder care. “We tend to try to avoid thinking about it,” said Oliver, “but the truth is, whether due to old age or disability, many of us do or will require help with daily living.”

From the Cuomo administration’s manipulation of nursing home Covid data to the terrible infection rates – nursing homes and assisted care facilities account for nearly a third of US Covid deaths – “the pandemic pushed an already strained system, to the absolute brink,” Oliver continued. “Covid has just exposed what we’ve basically known for years – that the way the elderly and disabled are treated at far too many of these facilities is, at best, indifference, and at worst, abuse and neglect.”

First, Oliver differentiated between the two standards of in-patient elder care in the US, nursing homes and assisted living facilities. Nursing homes are medical facilities overseen by registered nurses and staffed by low-paid nursing aides. The industry has long been plagued with entrenched issues of substandard care and poor wages – Oliver cited one study from before the pandemic which found that 82% of homes were written up for infection prevention of control deficiencies, and half had persistent problems cited for multiple years. Nursing assistants, meanwhile, are frequently overworked and underpaid – the average salary is about $30k per year.

Meanwhile, over the past decade, large nursing home chains including Life Care America, Extendicare, Ensign Group and North American Health Care have been charged with fraudulent Medicare billing practices and “denied wrongdoing while paying tens of millions of dollars to settle their cases – you know, like you do when you are totally innocent”.

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Much of this, as well as the actual standard of care provided in nursing home facilities, is masked by a “garbage in, garbage out” rating system in which nursing homes submit their own data without oversight. “That is pathetic – something as important as our nursing home rating system should not follow the same rule as every recipe on Velveeta’s website,” Oliver joked. “Because there is just no way any of those are any good.”

Assisted living facilities, in contrast, provide far less intensive medical support and thus are cheaper than nursing homes, costing on average $50k a year. The vast majority are also for-profit, but paid for out of pocket and far less regulated, “making it easy for basically anyone to start,” said Oliver, “and I do mean anyone.”

His case in point: Stephanie Costa, who appeared on the reality show Millionaire Matchmaker in 2013 with her small fortune on assisted living facilities in southern California. Costa racked up so many health and reimbursement violations that California banned her from the assisted living industry – at least, on paper. Costa’s homes are now listed under a property management company owned by her father, and she’s still the chief executive. “So the state of California really taught Stephanie Costa a lesson there,” said Oliver.

“Specifically, the lesson that you can treat your elder care workers like absolute shit, avoid any real consequences, and just keep living your life in the single ugliest home in Beverly Hills.”

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Cartoonishly bad managers aside, many assisted care facilities are rife with poor management of dementia patients, neglect and elder suicide. Oliver cited one bizarre and tragic case of an assisted living resident with dementia in South Carolina who left unnoticed in the middle of the night and was eaten by an alligator.

That facility was eventually cited for 11 violations, including insufficient night checks and understaffing, but fined merely $6,400. “And it feels like if you lost a loved one in such a horrific way, you would want more accountability than just ‘don’t worry, someone decided their life was worth the price of a 2013 Chrysler Motown,’” Oliver said.

The host proposed several regulatory changes to prevent such tragedies, such as mandated funds for certain types of care, standardized levels of care, and public funds for home-based care for the elderly, although “any aggressive transition to home-based care is going to need rigorous guardrails and oversight to make sure that money is not misspent, just in a different way,” he explained.

“The last thing I want is five years from now, having to do a show on the evils of new, for-profit home care agencies who’ve somehow been destroying people’s lives in their own homes.

“But we do need to do something, and it all starts with showing that we give a shit about what happens to the elderly and people with disabilities in this country,” he concluded. “Because right now, evidence points to the fact that we absolutely don’t, and all the other problems are stemming from that.”