by Karen Telleen-Lawton, Noozhawk Columnist(read the original in Noozhawk by clicking here)
The pandemic has been wrenching for nearly everyone, but an unmitigated disaster for nursing homes and their residents. AARP executive Bill Sweeney calls the crisis, “a moment like after 9/11, when people demanded change.”
The best I have heard from optimists is, “Something good will come of this.” I wonder what good will come of it, and how?
Nursing homes emerged relatively recently, according to the National Academy of Medicine (NAM).
The first step was the 1935 Social Security Act (SSA), which allocated funds to states to care for destitute older adults. Then Medicare’s acute care coverage and Medicaid’s long-term care coverage in 1965, “created a cultural and economic preference for institutional long-term care,” according to the NAM article.
Tweaks to the SSA since the 1970s supported some home- and community-based long-term care services amid changing demographics. But these and other changes haven’t adequately compensated for the shift in the past century toward most working-age adults participating in the workforce, rather than tending home, children and elders.
Prior to the COVID-19 pandemic, the American nursing home industry was dominated by for-profit institutions (70%), whose residents suffer a higher death rate than nonprofit residents. Health care workers labor in crowded facilities with little oversight, earning $13/hour on average.
Of the 15,000 nursing facilities representing home to 1.3 million Americans (2015), the Center for Medicare and Medicaid Services (CMS) rated almost half as only one or two stars out of five.
With this backdrop, it shouldn’t be a surprise that this system failed in 2020. Close to 40% of the COVID-19 deaths occurred in nursing homes and long-term care facilities.
One potential improvement may be allowing Medicaid reimbursement for recipients staying in their own residences. The crowding of frail residents with each other and staff, along with the forced separation from loved ones, likely exacerbated the pandemic among elderly poor.
Infection and disease are difficult to control when nursing home residents share bathrooms, especially where there are too few aides to help and clean.
The low pay for difficult work has several repercussions beyond insufficient support for the workers’ families. One is they can’t afford sick days, thus affecting their decision to stay at home or risk exposing their illnesses to others. Many workers work multiple jobs at multiple facilities, allowing diseases to spread among facilities.
Higher pay, less crowded facilities, and the possibility of reimbursed home care for the poor would all be major improvements. This approach probably means vastly improved enforcement of federal and guidelines. You could say the pandemic lifted the opaque veil exposing the poor value nursing homes are returning for our tax dollars.
One example: the CMS allotted $21 billion in federal COVID relief funds to nursing homes. Of this, $2.5 billion was allotted toward infection control, but there was no accountability on how the remaining 90% could be spent.
Elaine Ryan, vice president of state advocacy and strategic innovation at AARP, wondered where the money went. “We were asking, What’s happening? Do the staff have enough PPE? Is there any infection control?”
Despite the lack of oversight, the American Health Care Association, which represents nonprofit and for-profit nursing homes, has demanded federal and state legal immunity during the pandemic. At least 20 states have granted this immunity, providing little accountability for how our elders are treated.
Social Security funding also attracted some appallingly bad actors. Philip Esformes is a prime example. Federal prosecutors called his conviction, “the largest healthcare fraud scheme ever charged by the Department of Justice.”
Esformes, who ran a network of nursing and assisted living facilities in Florida, engineered $1.3 billion in fraudulent claims to Medicare and Medicaid for services. The maximum sentence would have been 255 years for his conviction on 20 felony counts; he was sentenced to 20 years. The 52-year-old Esformes served not quite 4 1/2 years before being pardoned by Trump.
Beyond these problems of provision, delivery and transparency, caring for the infirm elderly is expensive. Medicaid pays an average of $6,180 per resident per month. Nursing homes claim this doesn’t cover their costs; further expense is beyond the means of most American families. Long term care insurance is an option, but it is expensive, limited, and changes frequently.
For those of us already tiptoeing toward this age, our budget needs to include long term care as a major component. Whether we believe old age care should be the purview of the individual, insurance, or the government, we want to live out our days simply and safely. If the pandemic gets us to plan better as individuals and as institutions, something good will have come out of this.
Karen Telleen-Lawton, Noozhawk Columnist
Karen Telleen-Lawton is an eco-writer, sharing information and insights about economics and ecology, finances and the environment. Having recently retired from financial planning and advising, she spends more time exploring the outdoors — and reading and writing about it. The opinions expressed are her own.More by Karen Telleen-Lawton, Noozhawk Columnist