++Seniors want to age at home. But the US makes it hard. +
++The vast majority of Americans want to age in their home and community, spending their twilight years in a familiar and comfortable setting. But the choice is not always their own. +
++The US long-term care system — such as it is — is broken. Hundreds of thousands of Americans are on waiting lists for home-based care. More than 40 million people report that they have cared for a loved one over 50 without any pay in the last year. The United States ranks near the bottom of developed economies in the number of older adults who receive long-term care at home. Meanwhile, America’s nursing homes are staffed by overwhelmed and underpaid workers, and for-profit takeovers of those facilities have led to worse care for patients. +
++Covid-19 has made this long-term care crisis impossible to ignore. More than 130,000 nursing home residents have died in the pandemic, accounting for nearly one in four US deaths. Residents of large institutions died at higher rates than those who live in the community. +
++In America, aging people who need care — in a nursing facility or at home — either must be wealthy enough to pay for it themselves or must deplete their income and assets enough that they qualify for Medicaid. Almost by accident, the health insurance program for low-income Americans has become the main payer for nursing home and home-based care. Experts describe long-term care in the US with a sense of disbelief. +
++“If you were starting from scratch, you would never design a system this way,” David Grabowski, a Harvard professor who studies the economics of long-term care, told me. +
++Tricia Neuman, who studies long-term care at the Kaiser Family Foundation, put it even more baldly: “We do not have a system of long-term care in our country.” +
++America has been struggling for decades to figure out a balance between having people age in long-term care facilities and age at home. President Joe Biden has proposed a massive infusion of federal spending on home-based care. Experts say it should start to address these structural problems — but it’s only a start. +
++Long-term care in the United States has been broken for a long time +
++The story of America’s long-term care failure begins in earnest in the 1950s. +
++Before then, and really for all of human history, if you were lucky enough to age into your elder years, you probably aged at home. Nursing homes didn’t exist. But that also meant you needed somebody to take care of you — and that responsibility would often fall on a spouse or children or another family member. Women in particular often shouldered these duties. +
++Things started to change in the middle of the 20th century. More women entered the workforce during and after World War II. Americans became less likely to live as adults in the place where they grew up, with more people moving to other parts of the country to seek employment and settle down. Fewer family members were around to provide unpaid care, and so proto-nursing homes — alms houses, board-and-care homes — first appeared. +
++Then President Lyndon B. Johnson signed Medicaid into law in 1965. One of the benefits covered by the new program for America’s poor was nursing home care — but at first, there was no coverage for home and community care. +
++In the following years, and accelerating in the 1980s, more older people and people with disabilities were moved into institutional settings. The nursing home industry was born, and it boomed. Today, about 1.2 million Americans live in a nursing home. +
++Ideally, people would live in those facilities by choice. The most important principle for long-term care policy is personal agency: The patient and their family should have a right to determine what kind of care they receive. +
++But America has failed to live up to that ideal. More than three in four people over the age of 50 said in a 2018 AARP survey they want to stay in their community as long they can. But fewer than half thought that would be possible — and many of them may end up being right, as the long waiting lists for home- and community-based services attest. As of February 2020, more than 820,000 Americans were stuck on their state Medicaid program’s waiting list for home- and community-based services, according to the Kaiser Family Foundation, and their average wait time is longer than three years. +
++Even for those lucky enough to be able to afford in-home care, the US long-term care system hasn’t done them any favors. Virginia Veliz, a 70-year-old in Santa Clarita, California, has been coordinating care for her 90-year-old mother, who has Lewy body dementia and Parkison’s disease, for the past five years. +
++“You really have to treat it like a job,” she said. +
++Veliz lives with very specific fears about what would happen if her mom moved into a nursing home. Her mother is prone to urinary tract infections; they’ve put her in the hospital multiple times in the past decade. During a recent hospital stay, Veliz came to the room to find her mom, who has hallucinations because of her dementia, hanging over the side of her bed and “traumatized” by the isolation, she said. +
++With those experiences in her mind, Veliz cannot bear the idea of sending her mom to a nursing home, where she might be alone for hours at a time. Instead, she and her siblings are paying for home health aides five days a week, with physical therapists and physicians stopping by regularly. She knows they are lucky they can afford it, but, in the same breath, she jokes that they need a family therapist to navigate the stress of organizing their mom’s care. +
++“She just will not get the attention in a convalescent setting, because they don’t have the manpower,” Veliz told me. “What am I afraid of? I’m afraid of them not taking care of her. She’s very fragile.” +
++There are some people for whom institutional care makes sense — those with severe cognitive decline, for example. Others might simply prefer to live in a nursing home with other people instead of living alone at home. +
++But the idea is that it should be the patient’s choice. The US still has not found a way to put that decision entirely in the patient’s hands. +
++“There is a huge unmet need,” Neuman said. +
++Biden’s jobs plan includes a lot of new funding to expand home-based care +
++The crisis has been decades in the making, but the Covid-19 pandemic has made it impossible to ignore. +
++“The pandemic was an accelerant and gave momentum about how to move people out of facilities,” Neuman said. “You had families going to nursing homes urgently to get their parent or grandparent out, even at a great cost personally or financially.” +
++Gene Dorio, a California doctor who cares for Virginia Veliz’s mother, says he lost three patients to the coronavirus in the past year. As somebody who makes house calls to seniors and cares for patients in nursing homes, he did not seem surprised about the loss of life experienced in the latter. +
++“They ended up being at the wrong place at the wrong time,” he said. “The long-term care setting … some of these places are abominations.” +
++Finding a better equilibrium between community-based care and nursing homes will require money. Biden, as part of his American Jobs Plan, has proposed a $400 billion investment over 10 years into home- and community-based services. Many of the details would need to be determined when legislation is drafted in Congress, but the size of the investment alone has caught the attention of experts who work on long-term care issues. +
++Experts agree that resources — read: money — are the biggest challenge for long-term care. The challenges are so great that they aren’t sure $400 billion is “enough.” +
++“If the question is, ‘Is that enough?’, I don’t know,” Grabowski said. “Hopefully that will buy you a lot of community-based care.” +
++Neuman said more or less the same thing. +
++“It’s remarkable and unusual to see such a huge proposed investment,” she said. “How far this would go, I don’t know. But it is a significant investment.” +
++The money would presumably be spent, in large part, on home health workers. But there is a tension created by putting a hard number on that investment. +
++Experts say long-term care workers are underpaid for their difficult work (the average pay can be as little as $10 a day), so better compensation could lead to more people entering the field and staying in the work once they’ve started. Recent research showing some nursing homes see roughly 100 percent turnover in a given year suggests that retention is a serious problem in long-term care. +
++“You’re not going to get very far in fixing this without money. You need good caregivers. You need to pay them,” Grabowski said. “How do we ensure going forward that this is basically a better job, that starts with better pay and benefits?” +
++But the more you pay for one worker, the fewer workers you can hire. It’s simple economics. +
++That doesn’t mean the Biden plan couldn’t still do a lot of good. A single staffer could potentially help a lot of people. +
++But still: Virginia’s family has hired caregivers who stay with their mother eight hours per day, every weekday. That’s one salaried position for a single patient — and, eventually, with enough of those, even $400 billion could eventually run out. +
++The Biden proposal is not going to fix long-term care on its own +
++So the Biden plan isn’t a cure to the ills that afflict America’s long-term care, even if it is “a step in the right direction,” as Grabowski told me. +
++The pressure on the US’s broken long-term care system will keep growing. The number of Americans over 65 is projected to nearly double by 2060. Though Americans are working later in their lives, the number of people living in nursing homes could still reach 2 million, from the current 1.2 million, as soon as 2030. +
++That structural problem may eventually require structural reforms. Right now, the US doesn’t provide any government assistance to middle-income people who need long-term care. You are either wealthy enough to pay for your own care or you have to spend enough of your own money on long-term services that you become poor enough to qualify for Medicaid, and then that program takes responsibility for your bills. +
++“There still could be holes here for middle-income families,” Grabowski said, which he called “the forgotten middle.” +
++“There’s not a menu of services for this group,” he said. “That still isn’t here in this plan.” +
++There have been previous proposals to address that problem. The Affordable Care Act initially included what was called the CLASS Act, which would have created a voluntary public insurance program to cover long-term care. But the Obama administration quickly decided it would be too expensive and scrapped the program in 2011 before it ever got off the ground. +
++Prioritizing home-based care appears to be the preferred solution for both patients and policymakers. But it will cost money. The Netherlands, Norway, and Sweden are considered global leaders in providing community-based services, but they also spend a substantially higher share of their GDPs on long-term care (around 3 percent) than the US (0.5 percent). +
++On the other hand, the United States spends far more on other kinds of medical care than any other country. As Grabowski wrote in a recent Nature column, just 5 percent of that money is currently being spent on long-term care. +
++“Dollars could be taken from general health care spending and reallocated to [home and community-based services],” he argued. “This increased spending on HCBS would not only benefit the care recipients but also their family members, who often must take time away from their jobs and risk their own health to provide this care.” +
++And the choice is not binary between home-based care and nursing homes. The Netherlands in particular has experimented with small group homes, with much success. There is a similar model in the US, called Green House, a loose collective of homes with 10 to 12 beds that house seniors and are served by a small team of nurses. +
++Researchers have found that the residents of these small-group nursing homes were significantly less likely to contract Covid-19 or die of it compared to people who lived in larger institutions. The authors, from the University of North Carolina, concluded that small homes were “a promising model of care” as nursing homes are “reinvented” post Covid-19. +
++It’s hard to measure specific outcomes between aging in the community and aging in a nursing home. Tamara Konetzka, a University of Chicago professor, pointed out in a 2014 article that nobody was really sure which was “better” for patients from a health perspective, or which was more cost-effective. +
++But patient satisfaction and preference appears solidly on the side of aging at home. Rob Waters also covered Green House extensively in a recent issue of Health Affairs and clearly saw promise in the model. But he also highlighted how far it has to go: Right now, less than 1 percent of US nursing home residents live in a Green House. +
++“We just have a lot of ground to make up,” Grabowski said. “People want them. That’s where we should be directing services.” +
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++
++Blame John Roberts and Donald Trump. +
++Attorney General Merrick Garland announced on Friday that the Justice Department filed a lawsuit challenging several provisions of Georgia’s recently enacted voter suppression law. And the Justice Department has a strong case on the merits against this law. +
++Yet it is far from clear whether the strength of their case will matter: They will have to litigate this case before a judiciary that is increasingly hostile toward voting rights claims. +
++The complaint in United States v. Georgia, which is signed by the most senior lawyers in the DOJ’s Civil Rights Division, alleges that several provisions of the Georgia law “were adopted with the purpose of denying or abridging Black citizens’ equal access to the political process, in violation” of the Voting Rights Act. +
++The DOJ does not attack the entire Georgia law, and it does not directly attack the single most troubling provision of the law, which allows Republican officials to effectively take over local election boards that have the power to close polling places and disqualify voters. +
++Instead, the lawsuit focuses on several provisions making it harder to cast an absentee ballot in Georgia. It also targets provisions that disenfranchise many voters who cast a ballot in the wrong precinct, as well as the Georgia law’s provision prohibiting pro-democracy groups from distributing food and water to voters waiting in long lines to cast a ballot. +
++While the lawsuit only argues that these parts of the law violate the Voting Rights Act, it also asks the courts to invoke a rarely used provision of the Act which would place Georgia elections under federal supervision. +
++Before the Supreme Court’s decision in Shelby County v. Holder (2013), states with a history of racist voting practices, including Georgia, had to “preclear” any new election rules with officials in Washington, DC. Shelby County effectively deactivated this preclearance regime, but a provision of the Voting Rights Act still allows preclearance to be imposed on states that commit particularly egregious discrimination against voters of color. +
++And if preclearance were reimposed on Georgia, that would likely prevent GOP-controlled election boards from implementing policies intended to disenfranchise Black voters. +
++In another era, the Georgia lawsuit would have had a very good shot of prevailing. In Village of Arlington Heights v. Metropolitan Housing Development Corp. (1977), the Supreme Court laid out several factors which plaintiffs alleging race discrimination may point to in order to prove their case, including evidence that lawmakers departed from “the normal procedural sequence” that they ordinarily use to enact laws, the fact that a state has a history of racist practices, or the fact that a law’s impact “bears more heavily on one race than another.” +
++The DOJ’s complaint does an effective job of showing that many of these factors are present in Georgia. Yet while it has strong legal arguments on its side, the courts are now much more conservative than the Supreme Court that decided Arlington Heights — indeed, the current Supreme Court is even more conservative than the one that decided Shelby County. +
++The Georgia case, moreover, is assigned to Judge J.P. Boulee, a Trump judge. +
++The Justice Department, in other words, won’t simply need to prove its case, it will also need to overcome a judiciary stacked with judges who tend to be hostile to voting rights claims — and that are particularly hostile to claims that white lawmakers engaged in intentional race discrimination. +
++That will not be easy. +
++The Justice Department’s case against Georgia, briefly explained +
++The DOJ’s complaint lays out a fairly straightforward narrative against the new Georgia law. +
++Georgia, of course, has a well-documented history of racist practices. Yet, despite that history, Georgia voters elected the state’s first Black senator, Raphael Warnock, in the most recent election cycle. And the state also voted to elect Vice President Kamala Harris, the first African American elected to that office, when it went for President Joe Biden in 2020. +
++Part of the reason why this historically white supremacist state voted this way — and why the once solidly Republican state now has two Democratic senators — is an influx of Black residents. “The number of Black residents increased 70.7 percent from 1990 to 2010 according to decennial Census counts,” the DOJ explains in its complaint, “and Black residents’ share of Georgia’s total population increased from 26.8 percent of the population in 1990 to 30.6 percent in 2010.” +
++These Black Georgians were especially likely to use absentee ballots in the 2020 election cycle — so the law’s provisions limiting absentee balloting will have a disproportionate impact on African Americans if this pattern continues into future elections. (Although most of the spike in absentee voting in 2020 can be attributed to the pandemic, Black activists in Georgia have a history of using absentee voting drives to increase turnout.) +
++Black Georgians have also been much more likely to face long lines when they vote in person, according to the DOJ, which is why a law preventing good Samaritans from providing food and water to people waiting to cast a ballot is likely to have an outsized impact on African Americans. +
++The state legislature, the DOJ alleges, enacted the new law “with knowledge of the disproportionate effect that these provisions … would have on Black voters’ ability to participate in the political process on an equal basis with white voters.” The law passed without any support from Black lawmakers, and the legislature used an unusually rushed process to pass the bill. +
++Among other things, the GOP-controlled legislature bypassed the legislative committee that ordinarily would have overseen such a bill, and assigned it instead to a special committee chaired by a lawmaker who’d previously compared the “always-suspect absentee balloting process” to the “shady part of town down near the docks you do not want to wander into because the chance of being shanghaied is significant.” +
++The legislature also bypassed a process typically requiring such a bill to receive a “fiscal note,” a document laying out the bill’s likely impact on state and county spending. +
++Taken together, this and other evidence suggests that Georgia’s largely white Republican Party saw their grip on the state slipping away. The state’s Black population was growing, in numbers and in political power, and it just managed to elect a Black senator for the first time in the state’s history. +
++Faced with this impending loss of power, the DOJ alleges, white state lawmakers intentionally enacted legal provisions that they knew would diminish Black turnout — all in an effort to prevent African Americans from exercising the kind of political power they wielded in 2020. +
++Why this case faces an uphill climb +
++Even setting aside the fact that this case will be heard by a Trump-appointed trial judge, and then potentially by a federal appeals court and a Supreme Court dominated by Republican appointees, the DOJ will also have to overcome a raft of recent precedents undermining the Voting Rights Act. +
++The most harmful of these cases to the DOJ’s chances of prevailing is Abbott v. Perez (2018), a 5-4 Supreme Court decision handed down along party lines. +
++Perez held that lawmakers accused of acting with racist intent enjoy such a high presumption of racial innocence that few litigants will be able to overcome it. As Justice Samuel Alito wrote for his Court in Perez, “whenever a challenger claims that a state law was enacted with discriminatory intent, the burden of proof lies with the challenger, not the State.” +
++And Alito also went much further than simply placing the burden of proof on voting rights plaintiffs. The facts of Perez were simply extraordinary, and they suggest that few plaintiffs alleging race discrimination can ever prove their case. +
++In 2011, Texas enacted congressional maps that a federal court later struck down as an illegal racial gerrymander. In 2012, however, this litigation was still making its way through two separate trial courts, and the state did not have any lawful map that it could use to conduct its congressional elections that year. +
++Thus, to ensure that Texas could actually hold congressional elections in 2012, a federal judge drew interim maps that incorporated many of the districts that were later struck down. In drawing this temporary map, however, the judge emphasized that “this interim map is not a final ruling on the merits of any claims” that some parts of the map were illegal racial gerrymanders. +
++Then, in 2013, Texas’s Republican legislature took this interim map and adopted it as its own — effectively attempting to make the temporary map into a permanent map, despite the fact that it included several racially gerrymandered districts. And the Supreme Court upheld this 2013 law in Perez. +
++The 2013 map, Alito claimed, was “legitimate” because it wasn’t enacted with racist intent. Rather, he argued, it was enacted because Texas “wanted to bring the litigation about the State’s districting plans to an end as expeditiously as possible.” +
++Alito’s argument, in other words, was that the 2013 maps weren’t enacted to preserve a racial gerrymander; they were enacted to shut down litigation challenging a racial gerrymander. And, in Alito’s mind, that was enough to defeat that litigation. +
++The upshot of Perez is that the DOJ will now have to argue that the evidence that Georgia’s voter suppression law was enacted with racist intent is even more potent than the unusually compelling evidence of racist intent that was present in the Perez case. The DOJ will have to make that case before a Trump-appointed trial judge. And it may ultimately have to argue its case before a Supreme Court that is even more conservative than the one that decided Perez. +
++And then, if the Justice Department hopes to stop Georgia Republicans from taking over local election boards and using them to disenfranchise voters, it will have to convince the courts to impose a rarely imposed sanction on Georgia and restore preclearance in that state. +
++Perhaps the Justice Department can overcome all of these challenges. But the deck is heavily stacked against them, no matter how strong their case may be. +
++The emotional labor of creating a more accepting league should not fall to LGBTQ athletes. +
++This week, Carl Nassib, a defensive end for the Las Vegas Raiders, came out as gay on Instagram. He’s the first active player in the NFL to be out publicly — a major milestone for men’s sports. Nassib’s announcement was quickly supported by the NFL community and his team, making it seem like his roster spot will be safe for the upcoming season. In a masculine, cutthroat league where players can be released at a moment’s notice for any reason, broad acceptance of Nassib marks a shift. +
++Nassib is not the first high-profile football player to come out — that would be Wade Davis in 2012. However, Davis did not play in a regular season game, and he came out after retiring. On the eve of the 2014 NFL draft, another player, Michael Sam, came out. Sam was eventually drafted by the St. Louis Rams, but was cut by the team before the season began. After a short stint with the Montreal Alouettes in Canada, Sam retired. +
++While Sam has avoided the spotlight since retiring, Davis has become an activist and public speaker. In the aftermath of Nassib’s announcement, Davis spoke with Vox on what goes through an athlete’s mind when they play while closeted, and what steps he thinks both the NFL and society need to take to foster a culture of acceptance. +
++The following, in Wade Davis’s words, has been condensed and edited. +
++
+For me, playing sports while not disclosing my sexuality was a double-edged sword. In some ways, being gay offered me misguided motivation. Because I hadn’t wrestled with my own internalized homophobia, and I believed that I needed to prove something to heterosexual people, I felt I had to show that I was as good an athlete as the straight guys. It took me many years before realizing that I didn’t have to prove anything to anyone. +
++I wish I knew then what I know now: that not learning to love myself as gay was a much greater loss than the possibility of not playing football. And the journey back to myself was and is just as painful. What I am also learning is LGBTQ folks are not actually the ones that need to be accepted here. We have already done the really hard work of accepting ourselves. +
++Some of the work that is still left unchecked is in the language that we use. The language of “coming out” connotes this idea that we have something to hide and that we are monsters who exist in the closet. What’s true is that the world is acting monstrous toward us. +
+/cdn.vox-cdn.com/uploads/chorus_asset/file/22681849/GettyImages_1210632678.jpg)
Craig Barritt/Getty Images for Tory Burch Foundation
++We invite people in, as writer and activist Darnell Moore taught us. We extend an invitation to heterosexual people to not be so fearful of who we are. I would say that the work is for heterosexual people to see our ownership of our sexuality as a model for what it means to accept a part of yourself that the world says is unacceptable. +
++Because when they learn how to accept more of themselves, it makes it harder to reject someone else. If this shift happens and heterosexual people start sharing their stories of self-acceptance, it could crack open a space where you see more athletes who identify as LGBTQ, specifically in male-identifying sport spaces, because we trust that heterosexual folks have done the work. +
++Another shift that has to happen in sports is that coaches, other players, and owners have to get much more eloquent, much more sophisticated, and much more competent in their understanding of the differences between things like sex, sexual orientation, and gender identity, so they become less fearful of the fact that we’re going to be much more present, and much, much more visible in sports. +
++The majority of the labor right now is being done by women and LGBTQ folks. The work of women in soccer and women in the WNBA — who have had more openly LGBTQ athletes and coaches, and who have pushed social justice conversations further — has really been a model for other athletes. Women in sports have historically focused on building the collective power of the marginalized to effect social change, risking their careers, while too many men have been focused on the accumulation of individual power to dominate and control and not take the same risk. These women athletes, especially women of color, have had the right focus, and gay male athletes need to align ourselves with them. +
++The impact of Michael Sam cannot be denied, either. People saw Michael Sam, the kiss of him and his partner during the NFL Draft, as a spectacle. But what’s true is that it’s folks like Michael Sam who have used spectacle as a way to make it much easier for people to do what Carl Nassib did. We need to recognize the revolutionary spirit and action of Michael Sam, and not think that Carl’s announcement was somewhat better or more eloquent. +
++Transgender folks and folks who are deemed much more effeminate in their presentation have also done a lot of the labor that allows folks like myself and Carl Nassib to have the courage to be more open about our sexuality. Most people don’t imagine gay men being able to play sports like football, baseball, basketball, hockey, and soccer. Nassib’s announcement is part of a continual fracturing of that age-old myth. For younger folks who have had greater proximity to folks who identify as LGBTQ, this is the way it should always have been, and they’re saying, what’s taken everyone else so long. +
++Because when the labor of education and acceptance shifts, we will reach a new inflection point. Then we won’t see Carl Nassib’s invitation — as opposed to his coming out — as separate from other social movements. Because if marginalized groups can start to see a connection, then we will be able to move forward into a much more unified, collective front. +
++For now, though, Carl Nassib is another model for LGBTQ folks who like or play sports, showing that sports is a space not only where we exist, but where we belong. +
++As told to Sydney Bauer. +
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