Author

For over sixty years, the U.S. Department of Housing and Urban Development (HUD) has insured loans to nursing homes with the aim of supporting infrastructure improvements that can promote quality of care, especially for marginalized populations. Yet although HUD’s mortgage insurance program (termed “Section 232” in reference to the portion of the code of federal regulations in which it appears) has been in continual operation since 1959 and represents a substantial public investment, there has been little research on its impact. This Essay fills that gap by providing the first systematic analysis of the extent to which Section 232’s subsidies reach nursing homes with the greatest financial need and whether the program drives improvements in quality of care. Concerningly, we find that as a whole, Section 232 neither supports those homes most in need of capital nor drives improvements in quality of care at nursing homes. Rather, we find that Section 232 serves primarily as a refinancing tool for larger for-profit facilities and is underutilized by facilities serving vulnerable populations, with loans primarily going to facilities that disproportionately serve Medicare-covered residents in census tracts that are more white. In fact, not only do we find no evidence of improved quality in nursing homes that receive Section 232 loans, we find that such receipt is associated with practices that correlate with lower quality of care, including reduced nursing staff time. We conclude by considering the implications of these findings for federal long-term care policy, and propose specific reforms to better align Section 232’s operational approach with its underlying objective of expanding marginalized populations’ access to quality long-term care.

The supplemental appendix for this piece can be found here.

The last several years have been marked by contentious disputes about which governments represent the states of Venezuela, Libya, Yemen, Myanmar, Afghanistan, and Niger. Such disputes are far from idle curiosities—rather, they go to the core of the modern international legal order. States are the building blocks of the international legal system, but it is the consent of their governments that forms the cornerstone of international law and diplomacy. When the rightful government is contested, numerous questions emerge with enormous implications for both the states involved and the international community as a whole. Most critically, who is permitted to consent on behalf of the state—to military intervention, to treaties, to the use of state assets—or receive immunities? Who represents the state in international fora? Who is responsible for ensuring the state complies with human rights law and international humanitarian law? And what happens if different governments are recognized by different states and international organizations, as is not only possible, but common?

This Article aims to bring clarity to this debate. It begins by explaining the difference between state and government recognition. It then identifies seven important rights and responsibilities that accompany government recognition, ranging from the right to consent to military intervention to the obligation to uphold international human rights and international humanitarian law. It shows that individual states, and to a lesser extent, international organizations, are currently the primary actors in government recognition decisions. Their varying approaches to government recognition have resulted in incoherence and inconsistency that threaten to undermine international law. This Article makes the case for a new approach: granting the United Nations Credentials Committee, through the United Nations General Assembly, the power to determine the recognized government of a given state for all matters directly implicating international law. This approach would bring greater coherence to government recognition and would thereby strengthen the international legal order as a whole.