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Old People for Sale

The story of adult foster care in Portland serves as a fable to those who would claim that market forces are the best, most efficient, most effective way to meet our societal needs. In point of fact, commodification on the market robs important human relationships of their dignity and their meaning. This commodification can even be dangerous.
In any culture, the problem of compensation is fraught with difficulties. How does one decide which labor is worthy of compensation and which is not? How do we determine the relative value of different kinds of labor? In our society, we've always been taught that the market is the most effective and efficient means to make these decisions. The market unfettered, we are told, will smoothly and fairly allocate our society's resources to those most deserving.

Despite a few glitches, most of us have accepted this story about the world because we haven't noticed the many obvious examples to the contrary. It would be like looking for air; it's everywhere and has always been there, so we usually don't notice it. One of the "glitches" in the capitalist model has been the fact that, for most of the past 2 centuries in America, women's labor was expected to be done without compensation. The important labor of caring for home and family was not even recognized as "work" until very recently. Again, though, this was just a glitch, an anomaly, a temporary problem with the machine that could be fixed.

Until recently, I believed this story. I thought the way to fix this glitch was to compensate people for what has traditionally been called "women's work," to compensate people for providing care to those who need it. When I mentioned this belief, people often queasily noted that this would ruin things, that this would rob caregiving of its intimacy, that people should do it because it's a noble pursuit and a calling, not because it's a way to get money.

Somewhere deep down inside, I suspected there was something to this. But I usually responded by reminding those who shared this belief that no one says this to doctors. Healing the sick is a noble pursuit, and yes, people endowed with such a gift should give it freely from the goodness of their hearts. But they don't. Doctors make a lot of money. Why not those who nurse the sick in their homes? Why not those who care for elderly relatives? I saw it as a problem of sexism, which in large part, it is. When healing was women's work, it wasn't highly compensated. As soon as it became a man's world, its assigned value was raised. The solution, then, seemed to be to ensure that society compensates people for performing "women's work."

What I didn't see was that it was also a problem with the whole market system. It's a problem of capitalism. In this system, we need to perfom paid labor or we can't eat. We need access to monetary resources in order to secure food, shelter, and the clothes on our backs. We get those resources, not by creating the things we need ourselves, nor by doing intrinsically valuable things, but by doing things our culture is willing to pay for, at the rates it's willing to pay. In short, we need to sell our time and our labor so we can afford to pay for the goods and services that we would be making and providing for ourselves if we only had the time...which we don't have because we're busy selling ourselves on the open market.

So, for example, we must abandon the care of our families in order to move into the market sphere and work in unsatisfying jobs so that we can pay someone else to care for oour family members. Curiously, the same labor is often compensated when someone outside the family performs it. In other words, once it's removed from the collective of the family and privatized in the open market.

An entire industry has sprung up to expoit this niche. Whole corporations devoted to the privatization of caregiving have grown around our inability to provide the care ourselves in a capitalist system. Nursing homes, for example, take in the old people cast out by enforced necessity. And anyone who has walked the halls of a nursing home recognizes that this is not, in fact, the most effective, most efficient, healthiest way for us to meet this need.

Those who run nursing homes tend to make a lot of money at it. But the staff who work in nursing homes, the people who provide the hands-on care to our grandparents, are poorly paid, poorly trained, unskilled, and overworked. As a result, old people are abused and neglected in these facilities. Even in the "better" nursing homes, you will find people left in their beds all day with nothing to do. Those who can still get out of bed are usually wheeled into dark hallways to sit near the nursing stations, staring at blank walls and fluorescent lights. There is no time and little incentive for staff to provide any extras, often not even a "hello." Their relationship with patients is stricly business. There is no intimate, personal bond between people, no sense of commitment. Old people are simply a commodity, and the whole arrangement is simply a means to an end. Literally.

Yes, some people go into this line of work with higher ideals, but that's generally worked out of them within the first few months. Any sense of moral obligation is usually replaced by a desire to just put in the damn time and go home at the end of the day. It's hard, thankless work, and it doesn't pay enough, so what the hell.

Into this morass came the adult foster home movement. In the 1980s, nursing homes and all manner of institutionalization fell out of favor with Americans. No one wanted to go to a nursing home, and no one wanted to pay for them either. Like the deinstitutionalization of the mentally ill, the move away from nursing facilities was prompted by two different motives. The first was a desire to create a better environment for the people who had been confined there. The second was a desire to spend less money.

And so the adult foster home was born. As initially envisioned, it seemed very promising. People were supposed to welcome old people into their own homes, and care for them as they would their own grandparents. As an added bonus, they would actually get paid for this work. The nursing home industry had become so bloated that even paying people a small fortune to provide care in their homes would be cheaper than paying the exhorbitant prices for care in nursing homes. What could be better? It would get people out of the nursing home hellholes, and the market would reward the people who provided the care, thereby providing an incentive for people to get involved with this plan.

In the beginning, it seemed like it would work. People did begin to open their homes to old people, and to people with disabilities that made it impossible to live on their own. They changed the diapers, cleaned the linen, cooked the meals, dispensed the medications, and did all the other things that needed to be done. In return, they were compensated very well. So well, in fact, that people whose motives were less than pure began to see an opportunity here. A cottage industry grew around adult foster care. People began to open not just their own homes to the elderly, but other homes as well, leading to adult foster chains. They began to hire staff to look after the residents of these homes, and predictably enough, they tended not to pay this staff very well. Like the nursing facilities before them, they began to cut corners. Unlike the nursing facilities, they faced fewer regulations intended to protect their clients.

Today, the portland are has more than 600 such adult foster care homes. Many of them are nice enough, at least as good as the nursing homes were. But they're not like home. Giant, columned facades have repaced the homey exteriors in an effort to attract more "customers." Inside, appearances are attended to while care is often skimped. People often spend their day in their beds, just as they did in nursing facilities. The only activity generally offered in these homes is television. Watered down soup is often the main meal of the day. Sometimes, residents eat this soup in one wing of the "home," while the proprietors eat fillet mignon in another wing.

And why not? After all, they're making good money. They're allowed to have as many as five residents in each adult foster home, and they can receive upwards of $3000 for each resident. They can afford to eat well. Especially if they don't pay a lot for the meals they serve to the old people who are in their care, and especially if they don't pay much to the staff who serves those meals and provides that care.

Similarly, one often finds residents in these homes living in far less luxurious quarters than the propietors. Sometimes, the owners of adult foster homes live "in the big house," with large rooms, expensive furnishings and expansive views. At the same time, their clients often live in basements, or in a wing added onto the house with tiny bedrooms and little furniture. This is a "family" environment only in the most Dickensian sense. It's as if the proprietors have become, not surrogate families, but parasites living off the riches provided to them by the people in their care.

Go to these homes to talk to the proprietors, and you will hear mixed messages. In one breath, they will tell you how they do this out of the goodness of their hearts, how they sacrifice and slave to do this work, and how rewarding it is for them to help people. In the next breath, they will tell you they don't make enough money, they are over regulated, they shouldn't have to keep residents who exhaust their funds and go on Medicaid because Medicaid doesn't pay as much as private parties. They will explain that they leave residents in their rooms all day because they can't afford to pay for transportation or other expenses associated with doing more for them. They could, of course, but it would cut into their profit margin.

Many people who work in adult foster homes lack the skills and patience required for this kind of work. The market tolerates this lapse because it would presumably cost more to ensure that only those with the necessary aptitudes provide this kind of care. As a result, some older people suffer. Some people with alzheimers disease, for example, are abused because the caregivers do not understand their strange behavior and do not know how to deal with it appropriately. Where an understanding family member would have more patience, the overworked staff at these "homes" often prefers to sedate or restrain the offender. Sometimes medical care is skimped because providers do not want to pay for private nurses to check on patients. Again, this would cut into the profit margin.

The point is not that all adult foster homes are bad, but that the market is not a good way to meet human needs. There are flaws inherent in the capitalist system that are made obvious in this example. When caregiving comes with a price tag, the real value of that care inevitably goes down. People who are interested in making a buck tend to be different people than those who perform this work from a calling. When cold calculations about cost and profit are allowed to enter into human relationships, those relationships suffer. Dollar signs take the place of trust, honesty, sincerity, commitment, community. There appears to be no way to balance the need to compensate people equally for equal labor with the need to ensure that social bonds and intimacy be nurtured and protected from the poison of the marketplace.

Big business is coming for your grandmother, and it may just be that it's not worth the cost.

money changes everything 04.Oct.2003 18:09

cindi lauper

Capitalism absolutely leads to negative results. I'm sick of hearing how the invisible hand will fix everything, because it's just not so. Anyone who looks can see that. In the PDX anarchist clans, we have a sense of community, a willingness to do what needs to be done because it needs to be done. We create because we have to. We build and learn as a community, and ripping each other off is just not acceptable.

This is because the market economy is not allowed in to fuck everything up.

As soon as you start making calculations based on money, you devalue things. Anything you can't put a pricetag on is considered worthless, and you can't put a pricetag on anything important. Nursing homes are a perfect example of how this works. When people are "helping" people for profit, they pay more attention to how much they can get out of the people they're supposed to be helping, and how little they have to do for it. Capitalism is all about ripping people off. Greed is no foundation for a meaningful society.

Maybe we need to organize nursing home collectives! The old people can teach us the skills they have gathered, and can tell us their stories. We, in turn, can take care of the things they no longer can.

Care of the Elderly 04.Oct.2003 19:25


I agree with everything that has been said. I work as a nurse in the portland area and would like to see more funding for home health care, where I feel that the person has the dignity of being cared for in his/ her own home to their own rules and comforts. I know this isen't always possible , for example, a person with Alzheimer's Demetia, but if home health care was better funded more people could be taken care of in their own homes. After all how many rich folks do you ever hear of ending up in a nursing home? Most of them have private nurses.

Congregate care sucks 08.Oct.2003 11:54


I have long been involved with congregate care for people with disabilities. In almost every instance this type of care is demeaning, insufficient and costly. Several years ago, the trend moved from "group homes" to foster care homes. This was done not for the stated warm, fuzzy "homelike" environments but because it is cheaper (while not the norm - the average is probably in the 3K range, group home rates can go up to 10K+ a month per person) and there are less rules to follow (pesky rules about people's rights and care requirements) and less oversight by bureaucrats.

I have truly seen "hell holes" collecting big bucks (btw, they pay no taxes on their AFC income if the operators "live" in the home) and even with substantiated abuse cases, these AFC operators rarely lose their licenses. Besides the state payment (which is for their "care"), the individuals pay for their room and board (400$ + a month), they are left with "personal spending money of about $100 a month to buy themselves toiletries, clothes, any food not on the menu, medication co-pays, outings, etc. The disability rights community calls these places "mini-institutions" and they are spot on. Basically tax payers fund the keeping of people in poverty like conditions.

Oregon is however providing in home support funds for people with disabilities (because they were sued, not out of any humane consideration) however funds are limited to less than 10K a year. Its a step in the right direction but don't expect the warehousing of the old, the sick and the disabled to end anytime soon. And watch as national corporations slowly invade this landscape sucking up dollars and shitting out low wages and minimal care.

Yikes 15.Oct.2003 15:55


Last night I saw a TV commercial for something called afchomes.com and they boasted about having many homes in the area. I can't tell from their crude web site if they are a corporation or some sort of grouping of private homes but they sure can't spell or use appropriate nonoffensive language (on the "Advertise with us" link) hence "mental retard", "alzymers", "hearth diseases" (what your fireplace is ill ?). Normally. I'm not a spelling elitist but these people are supposed to be professionals. Oh, but they are making enough $ to take out cable TV ads.