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The Change We Deserve

Published on June 25th, 2020

As COVID-19 ravages the U.S., the nation’s nursing homes are the most dangerous places to be.  In the beginning, more than a third of those who died from the virus were residents or workers at nursing homes. In at least 20 states, nursing home deaths account for more than half of all deaths related to COVID-19. The nursing home industry has long operated out of public view with legal protections making it difficult to hold them accountable. Maybe now something will change.

The nursing home industry exists largely out of necessity, housing more than 1.3 million Americans. Most of these people cannot care for themselves and don’t have resources to pursue other options or family that can take them in. For many older Americans, nursing homes are their only choice, says Patricia McGinnis, executive director of California Advocates for Nursing Home Reform.

Elaine Ryan, vice president of government affairs for state advocacy at AARP, says the outbreak will push nursing home residents and their families to question whether many facilities should survive. “I think as the data becomes clearer, families and individuals are going to rethink if nursing homes are the best and safest places for them to be,” Ryan says.

AARP recently interviewed more than a dozen national experts to hear their views on what the crisis has exposed and what needs to happen for the industry to be safe and secure.

It is an industry paid for by our tax dollars. The federal government reimburses states to provide and pay for nursing home care for eligible seniors and people with disabilities through Medicare and state Medicaid programs, funded by contributions from the federal government.

Medicaid currently pays the bills for more than 60 percent of nursing home residents at a cost of more than $41 billion a year. But because Medicaid is a hybrid federal-state program, states have some discretion on spending, so benefits can vary dramatically based on where you live.  The problem is at least 70 percent of nursing homes are for-profit businesses so either they are not profitable or fraud, waste, and abuse take place.

Adding to the complexity is the range of nursing home types, often with different oversight or demands. Nursing homes for veterans, for example, are run by the Department of Veterans Affairs (VA). Nursing homes that serve people with dementia have far different demands than others.  Many offer other services in their facilities, such as short-term rehabilitation — paid for by Medicare — to keep beds filled and revenue flowing.

U.S. Sen. Chuck Grassley (R-Iowa) responded to the crisis by calling for strict oversight of nursing homes. The federal government has a fundamental responsibility to ensure that “the tens of billions of tax dollars that pay for long-term care” are well spent and pay for quality care, Grassley said in a statement.

Before the pandemic, government safety standards for nursing homes were not enforced, says Richard Mollot, executive director of the Long Term Care Community Coalition. Those standards should include increased focus on infection control — with rigorous enforcement.

We rarely see citations for low staffing, and generally there is no financial penalty, or it’s so small that it’s cheaper to just pay it instead of hiring a staff person,” he says. Mollot believes that federal and state regulations should require at least one registered nurse on staff at all times, as well as an expert responsible for preventing the spread of infections that plagued nursing homes long before COVID-19. If nursing homes fail to meet the mark, they should be fined or shut down, he says. In June, the federal government announced it would require states to increase focused infection control inspections of nursing homes — and said facilities that don’t comply will face higher fines.

Surveys by AARP are clear: Americans want to remain in their homes rather than move to a nursing home. However, current law requires states to use their Medicaid dollars solely for nursing home services, effectively cutting off stay-at-home options for countless older Americans. If a state wants to spend some of those funds to provide care outside of a nursing home, such as for home care or community services for the elderly, it needs to file for a federal waiver — a long, difficult process. That makes providing home care more difficult.

The coronavirus outbreak shows infection control fails when residents share rooms, toilets and showers, and when staff is forced to rush from room to room. It’s also bad for quality of life.  But that will require increased Medicaid reimbursement to nursing homes and changes in regulations.

We have consigned poor, frail, elderly people to a place where none of us would choose to be,” Kramer says. “We now want something different, but are we willing to pay for it?”

While health care professionals have been celebrated during this crisis, experts say it’s clear that nursing home workers face low pay, inadequate benefits, unsafe working conditions because of chronic under-staffing.  Staffing shortages put residents at risk as workers are forced to spend less time providing care causing unsafe practices and burn-out.

Caregivers should be paid well enough to get by on one full-time job, says Lori Porter of the National Association of Health Care Assistants. And staffing levels must increase so each worker cares for a handful of residents rather than dozens, she says. The national average pay for caregivers is about $13 an hour, Porter says. 

The cost to care for a person in a nursing home is high; Medicaid pays an average of $6,180 per resident per month, an amount very few Americans can afford on their own. Federal long-term care insurance program would allow more Americans to build up resources over time to fund care late in life.

Such shifts would allow care for frail elders to move from hospital-like complexes to smaller facilities with more individual care, or to their own homes. “Some states have made progress in moving to home care,” AARP’s Ryan says. “That requires more home care workers, and that is the struggle.”

Such dramatic change is hard. But if it is to ever happen, now is the time, Ryan says. “This pandemic has made us painfully aware that we can’t ignore our most vulnerable people. Americans always respond to a crisis. And there is hope that, with innovative ideas and bold actions, they will again.”

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