In 1982, seven people in the Chicago metropolitan area died after consuming Tylenol pills that had been deliberately contaminated with cyanide.
The perpetrator of the so-called “Chicago Tylenol murders” was never found, but the incident led directly to the adoption of strict new federal standards for over-the-counter medicine packaging by the end of the 1980s.
Johnson & Johnson, the manufacturer of Tylenol, won plaudits from the media and the public for confronting the issue head-on: The company voluntarily recalled Tylenol products from the shelves — a decision worth around $100 million in 1982 dollars — and offered a hefty reward for information leading to the culprit. Johnson & Johnson also introduced new triple-sealed packaging for its OTC pain relievers, and eventually switched from a two-part capsule to a single, more tamper-proof one-piece caplet.
More than 40 years later, J&J’s response to the Chicago Tylenol murders remains a core case study in prompt, effective corporate crisis management.
Contrast this response with that of the U.S. nursing home sector after COVID-19. The virus killed more than 200,000 residents and staff members in long-term care facilities in just two years. While the rapid, worldwide spread of a highly transmissible airborne virus was not the fault of nursing home operators, the pandemic revealed the endemic shortcomings that had plagued the sector for decades before, from low staffing to inadequate infection control protocols to a pervasive ageism that routinely de-prioritizes the health and well-being of elders living in communal care settings.
In the years that have followed, the federal government has slowly lurched toward nursing home reform measures — most prominently issuing a new minimum staffing standard for facilities via the Centers for Medicare & Medicaid Services (CMS).
I’ve written about why focusing on this single metric is an ineffective strategy for achieving the real systemic change that our broken eldercare landscape desperately needs. But the industry’s immediate, vocal, and lockstep opposition to staffing minimums reveals either a fundamental misunderstanding of how to properly respond to a crisis of confidence in the safety and habitability of nursing homes — or a painfully short-sighted attempt to maximize revenues today at the expense of the sector’s future.
Remember, Johnson & Johnson voluntarily took an enormous financial hit to protect its public reputation after the deaths of seven people in a single metropolitan area. Leaders knew that if consumers around the country couldn’t be sure that the Tylenol in their medicine cabinets was free from deadly poison — and if they couldn’t be sure that the company took these deaths seriously — they would simply stop buying it in favor of products from another company that committed itself to safety.
The death toll in nursing homes was orders of magnitude greater, spanning all 50 states. But when the government finally got around to applying a single reform based on decades of research, the industry fell back on the oppositional defiance that has come to define its relationship with regulators and the public.
The American Health Care Association and LeadingAge, the two major trade groups representing for-profit and non-profit eldercare organizations, respectively, have come out forcefully against both this specific staffing minimum and the concept of any staffing floor at all. The two organizations teamed up for a federal lawsuit against the rule; they also loudly support a bill in Congress that would prevent the Department of Health and Human Services (HHS) and CMS from ever issuing any staffing standard in the future.
Industry leaders further applauded a July Supreme Court ruling that hollowed out federal agencies’ ability to implement rules and regulations in any industry, with trade publication McKnight’s Long-Term Care News blaring a headline that typified the mood among execs on LinkedIn: “With the ‘Wicked Witch’ of regulation dead, nursing home staffing rule could follow.”
These are the same leaders who, when I ran competing nursing home trade publication Skilled Nursing News, never hesitated to complain that the media had it out for nursing homes. Why, oh, why do newspapers never write about the good stuff we do, like saluting veterans and taking residents on outings and helping people walk again after strokes? Why do they seem to hate us and focus on only the bad stories?
The short answer is that it’s not news to provide services that the government pays you to provide, but it is news when people are harmed in facilities that are meant to protect them. The blunter answer is that the media and public don’t trust you because you don’t give them enough evidence that you should be trusted.
You cannot complain about reporters with agendas from one side of your mouth while begging the federal government to erase the first major new regulation for nursing homes in decades out of the other, no matter how good or bad that regulation may be. You cannot insist on the industry’s inability to pay for safe staffing while bankrolling expensive lawyers and lobbyists to quash basic standards. You cannot respond to the deaths of 200,000-plus people with protests that you are the real victim. The court of public opinion simply doesn’t work that way; people’s bullshit detectors are far too functional.
"But it’s so unfair,” they’ll claim. “The pandemic wasn’t our fault, and neither was the fact that governments prioritized hospitals over nursing homes for things like PPE and financial relief.”
No, those things weren’t your fault, and I agree that the federal government deserves a huge chunk of the blame for the disastrous response to COVID-19 in nursing homes in the early days. The lack of PPE, the use of nursing homes as backup capacity for overburdened hospitals, the strict lockdowns that turned facilities into prisons for almost a full year — these were all enormous challenges that many providers handled ably amid a global crisis.
It’s also not your fault that caregiving jobs are culturally devalued, or that health care providers of all types are facing systemic shortages of qualified people, or that nursing home residents were among those most susceptible to infection and death from the coronavirus.
It's also crucially not the fault of everyone at these trade organizations. I think of AHCA and LeadingAge like news outlets: Just like a newspaper puts a firm firewall between its reporting and its opinion pages, there are plenty of people at both organizations who work every day to improve the lives of elders, and plot out a long-term future for the sector, independent of the public-facing lobbying efforts.
(I don't even think many of the people who vocally oppose the mandate are necessarily coming from a place of greed and malice; it's absolutely true that many markets don't have enough qualified people to fill open roles, and I understand the frustration of dedicated leaders who desperately want the best for residents but struggle just to find available staff — and who do not have the power to raise wages or spur other workforce investments on their own. There's also the cleavage of the issue along partisan political lines: If you're the type of person who thinks the government should let private businesses operate without interference, then you're likely already biased against this regulation on larger philosophical grounds. I happen to think those philosophical grounds are dead wrong in this case and many others, but I understand how it's difficult for people to see past their political priors.)
But it wasn’t Johnson & Johnson’s fault that somebody in the Chicago suburbs woke up one day and decided to tamper with random bottles of Tylenol on drugstore shelves. A drug manufacturer found itself in a nightmare outside of its control, and management responded like responsible adults leading a business that can have life-or-death consequences for its customers. It never publicly complained about the cost of scrapping countless potentially contaminated bottles of product, or the new ongoing cost of tamper-proof packaging — because they knew that it was either adapt or fold.
The nursing home industry, meanwhile, responded to a far bigger disaster as it always does: It’s not our fault, and even if it was our fault, it’s because we don’t have enough money and people are too mean to us. That kind of reaction may have worked when addressing individual instances of abuse and neglect at specific homes, but not when it’s in response to a system failure that led to hundreds of thousands of deaths.
I understand the logic behind this strategy — the lobbies exist to protect the financial interests of operators, investors, and other stakeholders first and foremost, so any new regulation that might cost any money at all is a major short-term threat. But there might not be a long-term future for nursing homes in this country unless something changes.
A July 2023 Gallup poll showed that under 20% of Americans would feel even “somewhat comfortable” living in a nursing home or having a loved one live in the setting, with 42% giving the industry a D or F grade for quality. State governments are increasingly shifting Medicaid funding away from nursing homes and toward the home- and community-based services that elders broadly prefer. Boomers have either already seen or will soon see the nursing home options available to their parents as they age, and will increasingly do anything they can to avoid a similar fate.
Since its creation in the wake of the Great Society reforms of the 1960s, the modern nursing home industry has coasted on the fact that it's generally been the only game in town for older people who need a higher level of care but cannot afford other options like private assisted living communities or in-home supports. Not independently wealthy and can’t live alone without some help anymore? It’s us or the streets, bub. You hear it in the way industry leaders use the threat of nursing home closures to head off new regulations that might cut into the bottom line: If you enact new regulations that we can't afford, we'll just close, and then where are these people going to go?
But that reality is changing, and the people with fortunes invested in the sector face a choice. They can cling to the past as long as they can, and squeeze as much money out of the existing system as they can, or an actual forward-thinking leader can decide to take some short-term pain now to build a better future.
The industry’s reaction to the staffing rule clearly demonstrates which option they’re choosing. Unless enough leaders can stand up and commit to creating something better — even if it means leaving a little bit of money on the table — we’re never going to build the kind of system I want to see when I’m in my 80s.
I’ve always been clear that home care can’t fix this system alone. Too many people don’t have stable housing where it’s safe to age in place, and too many people yearn for connection and community instead of a life spent at home alone with occasional visits from a care aide. We need robust, empowering, and dignified communal care options for elders who cannot or do not want to live alone, alongside robust, empowering, and dignified home- and community-based care options for elders who want to stay where they are.
The nursing home reckoning is upon us. There’s a future out there for providers who can think differently and invest in something that people actually want. But so far, the industry has demonstrated that they’d rather go down with the ship than find a new course.