By Richard T. Moore, January 19, 2026
Executive Summary
Massachusetts cannot meaningfully reduce acute care costs without confronting the systemic failures in long‑term care that drive avoidable hospitalizations, emergency department congestion, delayed discharges, and preventable complications. Chronic understaffing, inadequate clinical oversight, opaque ownership structures, and insufficient investment in public health and aging services create a cascade of downstream costs that fall squarely on the acute care system.
A comprehensive cost‑containment strategy must integrate long‑term care quality, public health capacity, and aging‑services infrastructure as core components of acute care reform.
Background
Massachusetts faces rising acute care expenditures, workforce shortages, and hospital capacity strain. Yet policymakers often overlook the interdependence between long‑term care and acute care. Older adults—who account for the majority of hospitalizations—move fluidly between these sectors. Failures in one inevitably burden the other.
Key Cost‑Drivers in Long‑Term Care That Inflate Acute Care Spending
- Chronic Understaffing and Insufficient RN Coverage
- High turnover and inadequate staffing lead to preventable falls, pressure ulcers, dehydration, medication errors, and infections.
- Lack of Registered Nurses on nights and weekends increases the likelihood that minor issues escalate into hospital‑level emergencies.
- These preventable events drive avoidable hospitalizations and ED visits that strain acute care capacity.
- Guardianship Gaps and Delayed DischargesI
- Insufficient numbers of qualified guardians leave older adults unable to consent to post‑acute placements or services.
- Hospitals become de facto long‑term care providers, with patients occupying high‑cost beds long after their medical needs have stabilized.
- These delays increase costs and reduce bed availability for higher‑acuity patients.
- Excessive Related‑Party Transactions and Profit Extraction
- Real estate, management, and consulting fees siphon resources away from direct care.
- Private equity and complex ownership structures prioritize returns over staffing and quality.
- Poor care quality leads to higher hospitalization rates and greater reliance on emergency services.
- Insufficient Public Health and Prevention Infrastructure
- Declining vaccination rates and weakened prevention programs increase the incidence and severity of infectious disease outbreaks.
- These failures disproportionately affect long‑term care residents, leading to surges in acute care utilization.
- Workforce Gaps in Geriatrics
- Shortages of geriatricians and geriatric‑trained nurses contribute to missed diagnoses, inappropriate prescribing, and unmanaged chronic conditions.
- Poorly managed chronic illness inevitably results in higher acute care spending.
Social and Fiscal Consequences of Inadequate Investment
- Federal Underinvestment in Aging Services
- Stagnant NIH funding for geriatric research slows innovation in dementia care, fall prevention, and chronic disease management.
- Failure to reauthorize the Older Americans Act weakens community‑based supports that keep older adults out of hospitals.
- Lack of progress on the Elder Justice Act leaves residents vulnerable to neglect and exploitation—conditions that often manifest as medical crises.
- Federal Limitations on the Personal Needs Allowance
- The inadequate Personal Needs Allowance undermines residents’ autonomy and contributes to social isolation, depression, and poor health outcomes.T
- These social determinants translate into higher medical utilization.
- Community and Family Impact
- Caregiver burnout increases when long‑term care systems fail, leading to more emergency calls and hospital visits.
- Loss of trust in the care system erodes public confidence and complicates policy reform.
Why Massachusetts Must Study These Cost‑Drivers Now
A study focused solely on acute care spending will miss the structural drivers that originate upstream. A comprehensive analysis must examine:
- Hospitalization patterns linked to nursing home quality
- Ownership structures and related‑party financial flows
- Guardianship delays and discharge bottlenecks
- Public health failures that disproportionately affect older adults
- Workforce shortages across the continuum of care
Without this systems‑level approach, Massachusetts risks repeating the cycle of short‑term cost cutting that produces long‑term cost escalation.
Policy Recommendations
- Commission a Comprehensive Cross‑Sector Cost Study
- Examine long‑term care quality metrics, hospitalization rates, and ownership structures.
- Include public health, guardianship, and community‑based services in the analysis.
- Strengthen Long‑Term Care Staffing and Oversight
- Require minimum RN coverage on all shifts.
- Increase transparency around related‑party transactions.
- Expand Guardianship Capacity
- Invest in public guardianship programs to reduce discharge delays.
- Rebuild Public Health and Prevention Infrastructure
- Prioritize vaccination programs and infection‑control capacity.
- Invest in the Geriatric Workforce
- Expand training pipelines for geriatricians, nurses, and social workers.
- Advocate for Federal Action
- Support NIH geriatric research funding.
- Push for reauthorization of the Older Americans Act and Elder Justice Act.
- Modernize the Personal Needs Allowance.
Conclusion
Massachusetts cannot solve its acute care cost crisis without addressing the root causes embedded in long‑term care, public health, and aging services. A systems‑level study is not optional—it is essential. The state’s fiscal sustainability, hospital capacity, and the dignity of older adults depend on it.