Author Judy Karofsky’s DisElderly Conduct: The Flawed Business of Assisted Living and Hospice (New Village Press, May 2025) is a riveting read. In it, she shares a personal account of navigating a slice of the U.S. health care industry with her late mother, Lillian Deutsch, who lived at six facilities during a five-year odyssey.

Karofsky’s eight-chapter book unfolds chronologically. The author’s eye for details, no doubt reflective of her career, e.g., one of Wisconsin’s first female mayors, an academic and real estate researcher, impresses. She captures multiple ebbs and flows of the corporate control of elder care, in which her aging mother suffered neglect and injuries, including sexual assault.

The impacts of what the author calls a flawed business model of elder care affect not only patients, such as her mother, but also their family members and employed caregivers. In fact, Karofsky becomes a major care provider for her mother as she experiences costly and subpar health care in a half dozen facilities. To use a dining metaphor, the portions are small and the price is high.

One inescapable conclusion from reading DisElderly Conduct is that the deficient elder care the author’s mother experienced is a systemic problem. I say that in part from reading Karofsky’s book, plus working in a skilled nursing facility (San Francisco’s Laguna Honda Hospital) and as a child of parents who experienced out-of-home elder care.

Unpaid female labor power in elder care that Karofsky provides parallels its central role in the household. That is, unpaid female labor of child rearing and partner supporting is a core feature of capitalist society. That feature allowed mothers to stay at home instead of enter the waged labor force in the postwar economy that ended in the 1970s when male workers’ family-supportive wages began to decrease as corporate America’s war on labor unions increased.

The corporate business model of elder care, e.g., 70 percent of which are units of assisted living and memory care, encapsulates for-profit enterprises. Accordingly, the corporate owners march to the drumbeat of profits first and patients and their employed caregivers last. Karofsky documents this social relationship and its negative impacts on her mother’s mental and physical well-being.

Speaking of employed caregivers, those with the lion’s share of the patient workload are Certified Nursing Assistants, or CNAs. They can be foreign-born and are overwhelmingly underpaid. They can also work irregular hours, disruptive to them and their families and patients.

Staff turnover due in part to irregular hours and insufficient wage-income is a symptom of this corporate-controlled employer-employee relationship. Further, CNAs are service workers in a service economy and among those suffering from the federal government shutdown and lapse in funding for food via the Supplemental Nutrition Assistance Program.

As the author’s mother’s health deteriorates, from strokes to a broken hip, she moves from independent living to assisted living. One of the key issues that the author focuses on, in addition to overlooked dietary restrictions, is monitoring her mother’s prescription medication regimen. It’s a grueling task, and readers get a powerful sense of the fatigue that Karofsky endures.

Big Pharma has its avaricious hooks in elder care. Haldol, oxycodone and lorazepam are

prescription medications that loom large as Karofsky’s mother ages and weakens. The author struggles heroically to ensure her mom’s caregivers and doctors are proceeding with all due caution to provide optimum health and wellness.

The author also drives home the lack of federal oversight and patchwork of state regulation for patients living in assisted living and memory care facilities. This structure benefits the corporate bottom line, not patients and their families paying out the rear. It’s an exploitative situation.

The footnotes in Karofsky’s book are helpful. The same usefulness applies to a Glossary at the back of her book. It is in many ways a primer on elder care in the U.S., though the narrative unfolds in the Midwest. In this respect, God’s Hotel: A Doctor, a Hospital and a Pilgrimage to the Heart of Medicine (Riverhead Books, April 2013), a memoir about the corporate capture of the country’s last alms house by Victoria Sweet, M.D., foreshadows DisElderly Conduct.

As the health of Karofsky’s mother deteriorates, she enters hospice. This final chapter of life as Karofsky reveals it is doubly difficult for reasons perhaps not widely known. One is the impending death timeframe for patients that governs Medicare )the federal health insurance program for Americans age 65 and older mainly) eligibility for hospice. That dilemma complicates an already fraught process.

The author’s policy prescriptions for reforming the current elder care delivery system make good sense. Such reform confronts corporate America and its unlimited campaign cash contributions to elected officials to craft policies that boost the bottom line of the owners and shareholders to the detriment of everyone else. In and out of the fight for humane health care, the class struggle is central to social uplift, to borrow a term from the late Rev. Martin Luther King.

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