Coyocan          An In These Times article by Ottavia Spaggiari sucked me in with a pull quote that blared, “As the United States faces the largest healthcare cuts in its history – set to strip $500 billion from Medicare and $1 trillion from Medicaid over the next nine years, leaving a projected 16 million people without coverage – Texas’ boarding home model could represent a painful preview of things to come.”  We all know about the horror coming from these cuts triggered by Trump’s budget bill to protect tax breaks for the rich by forcing the poor to pay in pain, but what in the world was this Texas “boarding home model’?  We’ve organized around nursing homes and home care for decades, but what in blue hell might this be?

Buckle up, because this is a terrible ride.  In Texas – and many other states – boarding homes are the term used to describe group homes for elderly or disabled people in private individual’s residences providing three hots and a cot under a roof with varying levels of support and frequently they “operate with little to no oversight.”  The car crash ahead of us is now coming into focus, as Spaggiari explains,

On their surface, the homes seem like a potentially good solution to complex social problems. As a low-cost, community-based model, boarding homes, which typically cost residents around $1,400 per month — compared with a median cost ranging between $5,475 and $7,087 per month for a nursing home bed — are often the only option for those who can’t afford a private nursing home or don’t qualify for Medicare or Medicaid. In Texas, the problem is compounded by two factors: one, that the state has the highest percentage of uninsured residents in the country, totaling about 5 million people, including many of Texas’ roughly 2.1 million undocumented immigrants; and two, that the state’s low Medicaid reimbursement rates have contributed to the closure of 84 nursing homes in the past five years and the loss of thousands of long-term care beds.

It takes no imagination to understand that his kind of dumping and warehousing of poor elderly and disabled is coming at us everywhere, and likely is already unseen, unnoticed, and potentially unregulated where we live and is about to explode.  When nursing homes and hospitals run past their legal obligations and don’t see the dollars to continue a patient’s care, these unlicensed makeshift workarounds are where they are discharging patients.

You say to-mat-o, I say tomato, so these boarding homes may be called “personal care homes” in Pennsylvania or “board and care home” in California or whatever in your state, but there is no federal oversight, inspections, or reports in most cases with any regulation that might exist coming from the state or, like in Texas, even county and local authorities.  Where Houston requires a local permit – and there are 300 registered – Texas has a model law, but compliance is voluntary for local governments.  The easiest way to understand this in a best case way is this is homecare in a group, residential setting supposedly providing “light housework, meal preparation, grocery shopping, money management, laundry services or assistance with self-administration or medication.”  Depending on the needs of the client, that might work, but with no oversight or inspection, corners will be cut, false claims of care will be made to families, and profiteering, abuse, and neglect will happen.  In fact, the Harris County DA has even found cases where “hospital discharge managers are incentivized to send patients to boarding homes…[and] sometimes receive a referral fee…” not that there is any other place for them to go.  Talking about Texas and many other states, especially now, where there are significant undocumented populations that are now restricted from accessing anything from health systems other than emergency services, where else will people go?

Without state and federal investment in alternatives and regulation, this is all going to get worse in Texas and everywhere else in the country, and the chances are slim of that happening anytime soon.  Affordability is at the heart of this crisis for the patients, making their right to choose meaningless when they have no alternatives, especially now that we are living in many states and a country without care.