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As increasing numbers of nursing home residents and workers receive the COVID-19 vaccines, it will be too tempting to say, “Great! That takes care of the problem with nursing homes.” Many of us will forget why at least 150,000 residents and workers in nursing homes died unnecessarily in 2020. They were victims of too-long-ignored problems in the ways that nursing homes are financed and managed.
Responsibility for improving the quality of care provided in nursing homes rests squarely with the federal and state governments. The federal government sets the minimum quality standards for nursing homes participating in Medicare or Medicaid, and the states are responsible for inspecting nursing homes to ensure compliance with the standards. The federal government funds the lion’s share of the two public insurance programs that pay for most nursing home residents’ care. Medicaid, the joint federal-state program for poor and low-income people, is the primary source of funding for the long-term care services needed by 60% of the 1.4 million nursing home residents. Eighty-five percent of such residents are 65 years of age or older, and have need for hands-on personal care that is not sufficiently provided in their homes. While Medicare only covers enrollees’ short-term stays in nursing homes for skilled nursing and rehabilitation care, it pays rates roughly twice what Medicaid pays and consequently provides a significant share of nursing homes’ revenues.
The Biden administration and Congress can take three actions to quickly and substantially improve quality of care and to reduce further unnecessary deaths and suffering in nursing homes.
First, they can enforce more stringently the quality standards that are already in place. For decades, the Government Accountability Office has found serious quality of care problems in nursing homes and has repeatedly recommended more effective enforcement, but to no avail. That is no longer acceptable. The time has come to apply significant penalties for staffing and other deficiencies, coupled with more frequent (including unannounced) inspections to assure compliance.
Second, the Biden administration and Congress can direct that Medicare and Medicaid payments support higher wages and benefits (including paid sick leave) for under-paid direct-care workers, and minimum amounts of supplies for control and prevention of infectious diseases. An estimated one in five direct-care workers in nursing homes (as well as one-third of those providing home care) earn so little that they themselves are dependent on Medicaid. Raising care workers’ wages and benefits immediately would provide essential pay to “essential workers,” helping to compensate workers for the stress and higher risks they take every day at work. Simultaneously, it would reduce employee turnover in nursing homes and attract more people into the caregiver workforce – not only to care for people in nursing homes but also to enable people who need long-term care services to remain in their homes.
Third, the Biden administration, with the Congress, should mandate and expand federal Medicaid funding for home- and community-based long-term services and support. Many states already fail to invest adequately in these services, and pandemic-induced declines in states’ tax revenues threaten their availability. The HEROES bill passed by the House of Representatives in May 2020 included a 14% increase in the federal share of Medicaid funding for coverage of long-term care provided in home- and community-based settings, which states now cover on a limited basis. The Senate refused to include the increase in the $900 billion stimulus bill passed in December 2020. The next round of relief should raise federal Medicaid funding for these much-needed services by at least this amount – up to and including full federal funding – to increase the availability of home- and community-based services in all states. Enabling more and better care at home will give people who need such care a choice, and will pressure nursing homes to improve their quality of care.
Vaccinating the residents and workers in nursing homes is essential to making them safer. But the vaccines are like a band-aid. They do not deal with the long-standing problems inherent in the financing and management of nursing homes that caused so many of our loved ones to die. Until the problems are fixed, a repeat of last year’s tragedy is only a matter of time. The actions outlined here can be taken swiftly by the Biden administration and Congress.
 Authors’ calculation based on Chidambaram, Garfield and Neuman (2020), Chidambaram and Garfield (2021), and the New York Times interactive website “Coronavirus in the US: Latest Map and Case Count” (last accessed February 2, 2021). About 37% to 40% of all COVID-19 deaths by the end of 2020 were attributed to nursing home residents and workers and the total number of COVID-19 deaths in 2020 was approximately 400,000 – for an estimate of 148,000 to 160,000 deaths among nursing homes residents and workers. We chose an estimate of 150,000. The number of COVID-19 deaths among nursing home residents and workers is believed to be an underestimate since not all states reported such data or consistently collected decedent data by nursing home residency or place of work, and some states (e.g., New York) are still revising their data with respect to place of residence.
Katherine Swartz is a Professor at the Harvard T. H. Chan School of Public Health and a Visiting Professor at Duke University’s Sanford School of Public Policy. For more than a dozen years, she has taught a seminar on health policy issues for an aging population. She also is known for her research on health insurance markets and why people are uninsured. She is a member of the National Academy of Medicine, the National Academy of Social Insurance, and was President of the Association for Public Policy Analysis and Management in 2009. For her work explaining why many Americans are uninsured, she was the 1991 recipient of the David Kershaw Award for research that has had a significant impact on public policy. An economist, she has a BS from MIT and a PhD from the University of Wisconsin.
Judy Feder is a professor of public policy and former dean of what is now Georgetown University’s McCourt School of Public Policy. A political scientist by training, she is a nationally-recognized leader in health policy and long-term care policy. Her scholarship at Georgetown University and the Urban Institute led to her election to the National Academy of Medicine. She has also served in senior policy positions in the Congress and the US Department of Health and Human Services; as former chair and board member of AcademyHealth and former board member of the National Academy of Social Insurance; and is a member of the Center for American Progress Action Fund Board and of the Hamilton Project’s Advisory Council. In 2006 and 2008, Judy was the Democratic nominee for Congress in Virginia’s 10th congressional district. Judy is a political scientist, with a B.A. from Brandeis University, and a master’s and Ph.D. from Harvard University.
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