The problem was systemic. Nursing home staff had too much to do in not enough time. At best, this meant neglect: Investigations found patients left in their own filth for days, infections and sores ignored, medical needs unmet and rehabilitation completely out of the question. “The dirt was indescribable,” testified one inspector to the United States Senate about homes she’d seen in New York. A doctor who treated patients from abusive nursing homes said they were often so dehydrated they couldn’t sweat or swallow. “The experience is so common in the hospitals in New York,” he testified, that “if you mention to a colleague that a new arrival is a nursing home patient, it means he is a comatose patient who has bedsores, is dehydrated and has pneumonia or urinary tract infection.”

At worst, patients were subjected to treatment close to torture. In a giant Pittsburgh-area nursing home, staff immobilized hundreds of patients every day because they could not manage their needs. If patients created “extra” work — for example, through incontinence — or spoke out about their treatment, they were subjected to punishment. Among countless such incidents, witnesses described seeing an aide spray cold water on the genitals of an African-American patient with diarrhea while insulting him with a racial slur. A woman named Dorthy, the neediest patient on her floor, had both diabetes and Parkinson’s, and was unable to move any part of her body except her mouth and her eyelids. When she asked for care, “she was screamed at, slapped and told to ‘shut-up’ many times by the staff.” Staff alternated starving and force-feeding her, and, according to eyewitnesses, played with the buttons on her adjustable bed, making it rock back and forth. A patient named Carrie, a blind woman, spoke out about the abusive conditions. The administration sent a psychiatrist to evaluate her, who described her as entirely clear-headed but recommended that she be committed if she continued not to cooperate.

While front-line staff were often the direct perpetrators of abuse, they did not cause the conditions that created it. The owners, administrators and policymakers who determined the shape of long-term care did that. When austerity strikes long-term care, it pits the workers — overwhelmingly likely to be underpaid and overworked women and people of color — against the patients, with results that can be horrifying.

The problem in the 1970s had deep roots. Previously, caring for older people was essentially unpaid women’s work, and only the extremely ill wound up in institutional settings. But the collapse of industrial employment and the single-breadwinner family in the 1970s, along with the passage of Medicare and Medicaid in 1965, drove a rising share of elder care into institutions. This process was especially pronounced in the areas we now call the Rust Belt, where prevailing economic arrangements were falling apart most rapidly, and the population was aging steeply as young people left to seek opportunity elsewhere. Demand for long-term care was rising while public budgets were crunched under pressure from de-industrialization and falling tax revenue. This was a recipe for abuse. It’s a pattern that the political theorist Nancy Fraser has labeled a “crisis of care,” a recurrent phenomenon occurring at economic transition points. The 1970s, at the end of the postwar economic boom, were one such moment. Now, in the long aftermath of the 2008 financial crisis, we are in another.

What the 1970s epidemic tells us is that the core dynamic leading to abuse in long-term care is the tension between declining funding and rising demand. This tension occurs when long-term processes of social change, like the aging of the population, coincide with short-term budget cuts. Long-term care is an extremely labor-intensive business, so wages and benefits are always the biggest line item in a nursing home’s budget — commonly as much as 65 percent of total costs. When Medicaid is cut, states will be forced to decrease the rates at which they reimburse nursing homes for care. Nursing homes will experience budgetary pressure, which will lead them to decrease the number of staff or the amount of time that staff can spend with patients.