The Commodification and Dilution of Assisted Living

Key Insight

Following the undeniable success of Keren Wilson's original model, the assisted living concept rapidly expanded, particularly after Oregon initiated efforts around 1990 to encourage the construction of more such facilities. Wilson's company, Assisted Living Concepts, evolved into a significant enterprise, becoming publicly traded and expanding to operate 184 residences across 18 states with over 3000 employees by 2000. By 2010, the population residing in assisted living facilities approached the number in nursing homes, showcasing its extensive appeal and strong market demand among individuals prepared to pay substantial sums to avoid traditional institutional care.

However, this swift popularization inadvertently led to a troubling dilution of the initial vision, as developers indiscriminately applied the 'assisted living' designation to diverse establishments, including redecorated wings of nursing facilities or sixteen-bed boarding houses, frequently offering reduced services. The focus progressively shifted toward safety and liability, resulting in stringent regulations that limited residents' personal belongings, mandated participation in specific activities, and imposed strict 'move-out conditions' that could lead to 'discharge' to nursing facilities. This medicalized approach, prioritizing safety and survival, paradoxically deprived elders of the very autonomy and opportunities for risk-taking that are often afforded to children, fundamentally altering the care environment from Wilson's initial intent. A 2003 survey of 1500 facilities found that only 11% offered both privacy and sufficient services for frail residents to remain long-term.

Wilson actively resisted this detrimental evolution, publicly expressing her alarm at how the concept was transforming. Her own company's board, driven by greater profitability, opted for constructing larger buildings in urban areas, eschewing low-income clients and advanced services, directly opposing her goal of establishing smaller facilities in smaller towns for low-income elderly on Medicaid. This profound conflict culminated in her resignation as CEO in 2000 and the sale of all her company shares. Despite this setback, she and her husband established the Jessie F. Richardson Foundation to persist in their advocacy for improved elderly care. Wilson notes that in most places, assisted living often fails to fulfill its original promise because it is frequently designed to satisfy the adult children's desire for their parents' safety and a 'hotel-like' aesthetic, rather than genuinely prioritizing the elder's own choices, autonomy, and desire for a meaningful life.