Aging in Place
Recently, my grandmother Louise and I have discovered new uses for the slender stainless steel device known as a turkey lacer. Usually, it stitches up an avian cavity; under our set of circumstances, it gently scrapes out my grandmother’s hearing aids and loosens Velcro rollers from her hair. Our discovery of the implement’s many uses has come out of a particular necessity. About three weeks ago, my extended family extracted Louise from her assisted living facility in Denver, which is owned by a company called Brookdale Senior Living, the largest operator of senior living facilities in the United States. In the frantic move, which was spurred by a sudden burst of Covid-19 deaths in her facility, as well as similar facilities around the country, several things were lost: whatever item is actually meant to clean her hearing aids, the shoehorn she needs, a few slightly-less-essential medications.
I’m giving Louise a pseudonym in case she ever returns to her Brookdale facility. Her boyfriend still lives there, as do many of her friends. She didn’t necessarily want to leave, but she also doesn’t know if she wants to go back: at the time of this writing, her facility has twenty-six Covid-positive patients inside, most of whom Brookdale moved there from their other facilities, with seemingly no warning to residents or most staff. If residents return to the facility, they must undergo a strict two-week quarantine—but everyone inside is already on lockdown, and the two-week clock resets with every new case. Effectively, residents in Louise’s facility have been quarantined for two months in their rooms, while on the fourth floor, Covid-positive residents from Brookdale facilities across Denver struggle.
News on the building’s death statistics comes to residents and their families via mass Zoom calls. We have tried to keep good cheer around Louise, removed so far from her home. After dinner one night, we trotted out a bag of crackerjacks that had come with her from Brookdale—staff had left them at each resident’s door, to cheer them up during their enforced self-isolation. We thought she’d be pleased, but as she began to snack, Louise looked slightly rueful. “I’ll have to check the bill at the end of the month,” she said, “to see if they charged me for these.”
The comment piqued my interest. The move was tiring, and Louise was sleeping a lot of the day. Filled with that restlessly angry quarantine feeling, I began to read two large tomes about private long-term care, released into the world nearly a century apart from one another—Thomas Mann’s The Magic Mountain for joy and humor, and Brookdale’s 10-K filings with the U.S Securities and Exchange Commission for everything else. More than half of Colorado’s Covid deaths have been tied to senior care facilities; I felt, reading, like I was working to fill in the background, the backstory of an unfurling plot. I didn’t yet understand the differences between assisted living, skilled nursing, memory care, independent living, and all of the other deadening terms that the senior living industry very carefully defines—for each has its own profit to make, and each unit can be fitted to another one, like a Lego landscape in which you stand “aging in place,” as the industry calls the very lucrative act of being alive.
“I’ll have to check the bill at the end of the month,” she said, “to see if they charged me for these.”
In the first few pages of Brookdale’s most recent 10-K, the document that most comprehensively sums up a company’s financial performance to investors, I read that although Brookdale only operates two senior living facilities in the state of Delaware (for comparison, they operate eighty-seven facilities in Florida), the company is what is known as a Delaware Corporation, incorporated there presumably for the state’s amorous relationship to its many big businesses. “The First State,” reported the New York Times in 2012, “land of DuPont, broiler chickens and, as it happens, Vice President Joseph R. Biden Jr., increasingly resembles a freewheeling offshore haven, right on America’s shores.” Reading further, I began feeling increasingly like that endlessly replicated gif so many have used to express the political web in which we’re stickily wrapped—Charlie from It’s Always Sunny in Philadelphia gesturing frantically at his complex diagram of an office mail system. It would be funny if it weren’t so numbing, the largeness of the Brookdale web, and the many directions into which one could look.
You could write a whole book, for instance, on simply the part of the story set in Nashville, where Brookdale is actually headquartered, in a little bronchiole of Brentwood, not far from where Taylor Swift keeps a house. There, too, sits one of the corporate offices of DaVita—whose logo you might recognize from their strip mall dialysis centers across the country—and HCA, the Healthcare Corporation of America. One of the first hospital management companies in the United States, it sprung up uncannily around the same time as Medicare and was structured explicitly after KFC. HCA, of course, remains slightly fragrant with Florida ex-Governor Rick Scott’s tenure as its CEO, during which, one might say, he oversaw the largest Medicare fraud in American history.
Today, for-profit health care companies in Nashville number more than five hundred. They rake in nearly $47 billion in annual revenue. Many of them have been backed by the same tangle of hedge funds, in different permutations over time, those vaguely pastoral names redolent of New England subdivisions: BlackRock, Glenview, Deerfield. Several of these for-profit health care companies donate, too, to the same Tennessee Trumper politicians (Brookdale via its own PAC): Bill Hagerty, Nashville native and free market health care proponent, and Marsha Blackburn, who has voted numerous times to repeal the ACA.
Propelled by the winds of private equity firms like BlackRock, Deerfield, and Glenview Capital Management, Brookdale has, in the past few years, set forth on a strategy of consolidation. They have worked to retool their portfolio through what the industry terms “targeted acquisitions and dispositions”; in other words, selling certain unprofitable properties while buying others, from other, smaller senior living companies. One familiar name here might be Emeritus, which submitted to Brookdale’s death kiss in 2014, after a ProPublica/Frontline investigation exposed rampant neglect, understaffing, and negligent wound care at their facilities. More recently, Brookdale has also worked on lease re-structurings with Real Estate Investment Trusts. The relationship between senior living facilities, REITs, and private equity is a bramble field, but the overall picture is that Brookdale has been consolidating and simplifying their operations with an eye, always, toward “scale”—that is, becoming a gigantic centralized operation that can serve smaller, dependent communities in cheaper ways inaccessible to smaller companies. Moreover, as the Times recently explained,
controlling the real estate gives investors, including real estate investment trusts, leverage to raise rents. Separating the real estate from the operating business can also help limit liability in wrongful-death lawsuits, because the latter typically has little cash and few assets.
Senior living companies are riddled with lawsuits, even as they benefit from lobbyists’ work to prevent lawsuits during the Age of Coronavirus. I’ll limit myself to listing three of Brookdale’s most awful ones: E Street Band member Nils Lofgren and his family are suing Brookdale after their loved one broke out of her nursing home four separate times, the last time from a memory care unit, eventually contracting coronavirus. A resident in Florida broke out and was killed by an alligator. And in California, a class action lawsuit is underway against Brookdale for alleged violations of the American Disability Act, as well as uniform understaffing. This lawsuit describes a disincentive on the part of building managers to request more staff from corporate, as managers might miss out on their bonuses if they do not hit a carefully prescribed earning target. In Denver, before Covid-19, Brookdale staff were often scheduled to move between different Brookdale properties, presumably to maximize efficiency. This is what they told my mother, anyway, when she called to inquire about why Louise hadn’t gotten her medication.
Could there be any starker exhibition of class in this country than a seventy-four year-old health care worker caring for a seventy-six year-old who can afford it?
One joy of scrying the bowels of any industry is examining the bevy of analysts who, unlike corporate executives, are able to practice some creative writing. Senior living is no exception, and the creativity has abounded in response to endlessly dire news of exponentially multiplying death. One writer recently called for industry lobbyists to work in the nude and another started her article with a hip little quote (“It’s the end of the world as we know it . . . and no . . . I am not feeling fine”). But the hip references of the eldercare industry seem to end in the nineties—“In the mosh pit of senior living challenges,” wrote one analyst at Senior Housing News, “labor arguably presents the gnarliest problems.” Brookdale might put it differently in its 10-K, but the gist remains the same—minimum wage increases in recent years have pushed up their labor costs. Offsetting these costs—already minimized wherever possible—has meant increasing resident fees. “Most of our residents fund their stay with us through pensions and other fixed-income savings,” said Brookdale CEO Lucinda Baier in a recent earnings call, with, among others, a representative from Barclay’s. “And so we haven’t necessarily seen that residents have to sell their home to afford our services, but we do think that the ability to sell a home and to convert those assets into cash is helpful to us, if that makes sense.” At Louise’s facility, large television screens bordered the elevators, displaying winsome photographs of Brookdale sales associates high-fiving each other after breaking some record number of units sold.
But making up for higher labor fees has also meant rolling the available staff as thin as possible. Personalized Living, Brookdale’s customizable service providing everything from “companionship” to “toileting,” is an expensive add-on. But long before I was helping to care for Louise, we felt the effects of understaffing—PL simply could not deliver on Brookdale’s promises, and Louise repeatedly missed her medication or was stranded without the wheelchair she needed to leave her room and go get dinner. State ratios dictated by the Centers for Medicare and Medicaid Services specify how many care providers there need to be, per group of residents, in a long-term care facility. Even sticking to this ratio as a minimum, though, means there is simply far too much work, and not enough people hired to do it. Covid’s crash of the economy has inspired Brookdale to hire 4,500 new employees—a promising piece of news tempered by the realization that it’s perhaps never been cheaper to do so. Moreover, before Covid hit, the senior living industry news was citing some new statistics from the Bureau of Labor with excitement. Elderly people would not just be clients, but workers, with 30.2 percent adults age sixty-five to seventy-four in the workforce by 2026! Could there be any starker exhibition of class in this country than a seventy-four year-old health care worker caring for a seventy-six year-old who can afford it?
On the whole, senior living is in bad shape. Brookdale has suffered net losses since 2005. Before Covid-19 hit, the company was focused on one of those words that means nothing and everything—“streamlining.” They had big plans to “pilot a more integrated healthcare service model,” and to deepen and expand what they call their “healthcare services business, primarily by growing our hospice and home health business lines,” as well as by growing their private duty business—sending care professionals into residences outside of their buildings. While most aspects of hospice care, and much of Brookdale’s “home health” ventures, are reimbursed by government programs, Medicare in particular, “non-covered services,” reads the 10-K, are “paid directly by residents from private pay sources.” In other words, this is health care, and hospice, a la carte. By expanding their services to seniors outside of their communities, to use Brookdale’s own language, they would in time increase move-ins—one of the most important metrics of health for the senior living/housing industry. Everyone, after all, is literally aging in place—the senior living industry just wants that place to be, eventually, in one of their buildings. Trademark filings from earlier this year echo this strategy: in February, Brookdale filed trademark applications for “BROOKDALE HEALTH+” and “BROOKDALE HEALTHPLUS,” for, presumably, a lucrative new arm of business expanding on Personalized Living.
I had to take a break from the 10-K and associated documents. The story they told was not unexpected, but it was dense with information, written in such a way to suffocate what the writer Christina Stead once called “the eels in [our] souls.” The presence of hedge funds, of understaffing, of pivoting further to for-profit hospice, of “aging in place” for decades in a Brookdale facility, of excitedly partnering with third-party tech companies to further lower costs: these things were now, in the news, being linked to Covid-19’s flourishing inside senior living facilities’ walls across the country. So instead of reading, I listened to those weekly Zoom calls with the director at Louise’s Brookdale facility, sent out in .m4a format, which I found myself staring at, the eels in my soul whispering Medicare for All. The calls were full of strange, funny little moments; for as stilted as they were, there was room, still, for the foibles of actual people. “Pam, you need to click the share screen button because we all can see your screen.” “On the fourth floor, if the virus were to get out of the window, would it float up or down?” “The men are all going to have man buns by the time this is over.”
In other words, this is health care, and hospice, a la carte.
Then, oddly, a point of actual connection in the middle of isolation: staring at a New York Times article on private equity and nursing homes, I found that I had gone to high school in East-Central Illinois with one of the authors of a cited study. I called Constantine Yannelis up, and he told me that he and his co-authors were continuing to work on the study, which had found a correlation between private equity-owned nursing homes and their quality ratings—after private equity comes in, nursing homes tend to reduce their staffing, with an eye toward efficiency. “There is also a preliminary,” and here Yannelis stressed the word preliminary, “correlation between private equity ownership of nursing homes and Covid deaths.” As he spoke, not only did the eels of my soul stir, but a few feet from me, two red coachwhip snakes raced across the ground, roiling in frenetic copulation. I ran inside, away from the metaphor.
After hanging up, I read that the hedge fund Deerfield, managed by James Flynn, is creating an “innovation campus” on Park Avenue South in Manhattan, where academic institutions and biotech companies alike will entwine and mate at something called the “Cure Lounge,” a “thought leadership and executive club” that Flynn announced with grandiose “now more than ever” language.
You can see this connection as murky, or you can see it as clear. Same goes for a brief interview I did with Vicki Freed, who sits on the Brookdale Board of Directors while simultaneously working as Senior VP of sales for the cruise line Royal Caribbean International. “In a way,” she told me, “you could say that senior living is kind of a cruise ship on land.” Indeed. Freed made sure to speak of Brookdale’s post-Covid strategies, how much work they were doing, on a corporate level, to react aggressively. Yes—I had heard, in a Zoom call a week before, about the tractor-trailer stuffed with N95 masks that had spontaneously combusted on the highway, on its way to various Brookdale facilities. I had read, in the Denver Post, about the Dixieland band hired to play outside of a Brookdale facility an old spiritual about “laying my burdens down.” I knew all about the LifeShare app, which residents were being instructed to download for up-to-date information on the virus in their building, though several such apps seemed to exist in the App Store, and no one could figure out which one to use. I was aware, too, that as part of Brookdale’s “action phase,” they “posted nineteen separate videos during March and April.”
This is not to say that staff in Brookdale were not working hard. In fact, I think they were working back-breakingly hard, for a median annual salary of around $20,000. The CEO of Brookdale, Lucinda Baier, makes 317 times this number, according to recent financial statements, and that’s without taking into consideration her stock ownership.
If Louise weren’t resting nearby while I read Brookdale’s 10-K, I would mostly forget that there were people involved here—both in charge of and dependent on the company’s formulations. I’m reminded of the way many of us default to “the algorithm,” supposedly faceless and objective, as the explanation for the images we are supplied with, the brands we are prompted toward, the prices we end up paying. But I remember, too, the journey toward Louise’s apartment in her Brookdale facility. You parked your car and you walked across the large entry area, in between benches where elderly people smiled at you and looked you up and down, assessing whose grandchild you might be. There, right there, on the street in front of this building, is where just a few weeks ago, Brookdale put up a tent. “What was that tent in front of the building,” a resident inquired during a recent Zoom call. “We are still engaging and throwing marketing events and letting people know we are still here,” replied the Brookdale representative. It was a drive-through party, she said, for sources at the hospital referring new clients to Brookdale.