infacilitiesthatmetbasichealthandsafetystandards.A
significantnumberofhospitals,especiallyintheSouth,
couldn’t meet those standards. Policymakers feared a
majorbacklashfromelderlypatientswithMedicarecards
being turned away from their local hospital. So the
Bureau of Health Insurance invented the concept of
“substantialcompliance”—ifthehospitalcame“close”to
meetingthestandardsandaimedtoimprove,itwouldbe
approved.Thecategorywasacompletefabricationwith
nolegalbasis,thoughitsolvedaproblemwithoutmajor
harm—virtuallyallofthehospitalsdidimprove.Butthe
bureau’srulinggaveanopeningtonursinghomes,fewof
which met even minimum federal standards such as
having a nurse on-site or fire protections in place.
Thousands of them, asserting that they were in
“substantialcompliance,”wereapproved,andthenumber
of nursing homes exploded—by 1970, some thirteen
thousandofthemhadbeenbuilt—andsodidreportsof
neglectandmistreatment.ThatyearinMarietta,Ohio,the
nextcountyoverfrommyhometown,anursinghomefire
trappedand killed thirty-two residents.InBaltimore, a
Salmonellaepidemicinanursinghomeclaimedthirty-six
lives.
With time, regulations were tightened.The health and
safetyproblemswerefinally addressed.Nursinghomes
are nolonger firetraps. But the coreproblem persists.
Thisplacewherehalfofuswilltypicallyspendayearor
more of our lives was never truly made for us.
ONEMORNINGINlate1993,Alicehadafallwhilealone
inherapartment.Shewasn’tfounduntilmanyhourslater
whenNan,whowaspuzzledatnotbeingabletoreach