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PaperclipPerfector  5mo ago (text post)   24877 thread views

Culture War Roundup for the week of October 30, 2023

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Staffing Shortages in Nursing Homes

Recently the House Energy and Commerce Health Subcommittee held a hearing about two new Biden Administration rules impacting staffing in nursing homes.

The lay of the land is that everyone in both parties agrees that we have a critical lack of workers in nursing homes. There have been more than 500 long term facility closures in 2020, and we would need to fill 150,000 jobs just to reach pre-pandemic levels. One of the witnesses mentioned that most nursing homes do not have anywhere near the minimum number of staff that the Center for Medicare and Medicaid Services considers a requirement to be safe. Higher numbers of staffing are also associated with higher quality patient care and lower deaths. Some witnesses related horror stories of nurses not being able to wash patients who had soiled themselves because they were dealing with more urgent medical situations for other patients.

This is especially urgent because by 2030 all 75 million of the boomers will be over 65 and the demand for care will only continue to rise. So the Biden Administration has proposed two rules to address the situation.

1 - The Proposed Minimum Staffing Rule would require there to be a registered nurse on-site 24 hours a day (up from 8 hours currently), and a ratio of one nurse for every 44 residents and one nurse aid for every ten residents.

• Republicans objected that the Kaiser Family Foundation found as many as 80% of nursing homes would not be able to meet the minimum staffing requirements, and compliance costs alone would be tens of millions per state. This would be especially difficult for rural nursing homes where trained staff are rare.

• Democrats responded by pointing out that the rule phases in over three years, gives rural facilities five years, and makes full exceptions for nursing homes that are trying to find staff but can’t.

• Republicans also claimed there simply aren’t enough trained staff out there to be hired, which makes the requirement impossible. It’s unclear if this is true; the witnesses were pretty evenly divided.

• (Related tidbit from outside this particular hearing: Senator Bill Cassidy, Bernie Sanders’ Republican counterpart on the Senate HELP Committee, has complained that we have a shortage of trained nurses partially because many states require nursing colleges to be taught by nurses with masters degrees, who are few in number and already mostly working as practitioners. I can buy this because in my experience looking into other healthcare issues, state level regulations often do make federal laws go much less far. For example pricing transparency rules don’t really matter when states allow hospitals to be monopolies.)

• Democrats responded that the rule provides $75 million in grants to train nurse aids, and also pointed out that Democrats repeatedly have tried to boost federal spending to help with this kind of training and hiring but Republicans were opposed soooo.

2 - The proposed Medicaid Access Rule would require home health agencies to pass through a minimum of 80% of funds to direct health care work force.

• Republicans objected that this only leaves 20% of funds to handle everything else: administrative costs, facilities, training, supervision.

• Democrats countered by demonstrating that non-profit nursing homes were spending on average 43 more minutes per patient each day than for-profit nursing homes, and this held consistent across urban vs rural areas as well as rich vs poor areas. Meanwhile, for-profit orgs are also, obviously, walking away with more profit. Thus, the 80% rule is just a way of ensuring that the federal funds goes to our most critical problem: staffing and patient care, since clearly you can’t rely on businesses choosing to do this on their own.

It's a crappy situation. Basically everyone agrees that the current status quo is unacceptable, but also nursing homes genuinely don't seem to be the funds to hire the desperately needed more nurses, even though they were able to (at least moreso) only a few years ago? The only solution seems to be raising federal funding for nursing homes to hire more people, but this is unlikely to happen any time soon. It would probably be easier to get everyone to agree on stuff like lifting the supply restrictions on nursing colleges, but of course that happens on the state level and is much more complicated to address from the federal side.

Ahh when fucking with demand and supply and credentialism bites you again but the solution totally isn't getting rid of those things. The only solutions on the table both sides will put up is more fucking with demand and supply. You reap what you sow?

What about... filling the gaps with immigration? There's like millions of Thai and Filipino nurses you can fill up the shortage with without crossing the budget. It's not like you need a PhD to change diapers anyways.

Democrats have proposed several bills for allowing immigrants to work in the healthcare space: the International Medical Graduate Assistance Act of 2022, the Immigrants in Nursing and Allied Health Act of 2022, and the Professional’s Access To Health Workforce Integration Act of 2022. The Republicans control the House though and don't support having more immigrant workers so none of these bills got a vote.

On the Senate side Bernie Sanders proposed the Bipartisan Primary Care and Health Workforce Act of 2023 last month, working together with Republican Roger Marshall from Kansas who is NOT the ranking member on the HELP Committee. The actual ranking member is Bill Cassidy who was opposed to the (admittedly really high) price tag and will definitely oppose it since they basically circumvented his authority.

Still, overall the Senate is overall less polarized on this issue than the House. Actually just yesterday Durbin of Illinois (a Democrat) and Cramer of North Dakota (a Republican) proposed a bill precisely for this, with a bunch of co-sponsors across both parties. I don't think the text of the bill has been released yet but here's an excerpt from the press release:

• Allows for the “recapture” of green cards that were authorized by Congress but unused in previous years, allotting up to 25,000 immigrant visas for nurses and up to 15,000 immigrant visas for physicians, as well as recaptured visas for immediate family members of such individuals;

• Requires employers to attest that immigrants from overseas who receive these visas will not displace an American worker;

• Requires eligible immigrant medical professionals to meet licensing requirements, pay filing fees, and clear rigorous national security and criminal history background checks before they can receive recaptured green cards.

Almost certainly DOA in the House though.

Would more visas for doctors help if they're competing for the same limited number of residencies? I'm married to an IMG with ECFMG certification but she didn't match not even an interview.

I'm not sure if this is happening in nursing homes specifically but within the last five years healthcare has had a massive problem with outside investors (most notably PE in emergency care) buying stuff up, extracting as much money as possible and then leaving the thing to go out of business (not that this wasn't a chronic issue it's just gotten a fuck load worse).

I suspect the issue is similar here where these places cut costs like crazy, provide terrible care, and then croak but only after someone has already run off with the bag.

example:

https://old.reddit.com/r/medicine/comments/17e0hw0/private_equityowned_air_methods_the_united_states/k603nkk/

While everyone else is talking about the supply/demand portion this additional portion is important - yeah if your ED physician group goes out of business those doctors will find other groups or jobs most likely, but the amount of unnecessary friction caused gets people killed and creates a lot of economic loss.

Good point, and I'm hoping to do a longer write up on the impact of private equity on the healthcare market in general. One of the interesting pieces of legislation being debated right now is site-neutral pricing, where one hospital system can't charge different prices for the same services at different facilties. Ideally it's supposed to combat the recent spread of PE backed hospital orgs buying up private practices and charging wildly inflated "off-campus/off-site" fees to visit those doctors.

Nursing homes are in aggregate a symptom of a social disease- end of life care for the elderly and the infirm is atrocious.

Society has kicked families out of their homes, and left the elderly out to dry, while simultaneously sucking up adult children's time that would be spent caring for the elderly in their last years.

The problem is that historically, we simply didn't have the technology to keep them all alive, usually, when elderly would spiral, they would spiral relatively fast- infection, diabetes, cancers, all things that had no cure in the ancestral home. In the current era, we just wait for them to decline, and while we have cures for the most major diseases, we have nothing to help the elderly live more fulfilling and yes, even economically-productive lives. They are shoved into a heartless building where they play bingo on Tuesday at nine am and wait for god to come knocking, with the very occasional visit from what remains of the local evangelical churches activities.

Yes, there are problems in nursing homes, but no, there's no incentive to solve it, one way or the other. The country seems locked in indecision on this particular issue. The AARP is the largest focus group in the US, and as a bloc, holds a stranglehold on the younger generation's ability to help them solve their problems. Young and middle-aged voters are similarly out-of-sighting and out-of-minding the entire problem- shove the elderly into a nursing home and visit once a month until they die-if you're nearby. Maybe do a task that the nurses haven't gotten to. Then move away when offered a raise or a new job in a new state.

Ol' granny's got 5 years still left in her, nevermind that she can't make her way to the toilet any more, but her son Kyle is 50 years old and still in his career and living in tennessee, five hundred miles away.

Society has kicked families out of their homes

Phrasing it that way is a tad too extreme and simplistic, I'd say.

Anyway, one reason I find this news a bit strange is due to one argument I've heard from normies about this, namely that so many elderly have supposedly died from COVID in nursing homes that those've become less crowded than before. To be fair, it does sound like BS.

Society has kicked families out of their homes, and left the elderly out to dry, while simultaneously sucking up adult children's time that would be spent caring for the elderly in their last years.

I know there's no great solution to this problem in general, and no one in my family has lived long enough for it to be an issue, but the idea of putting my mother in a nursing home fills me with a cold dread.

What about the idea of changing her diaper, washing her entire body, carrying her around the house, feeding her, changing dressings, etc...

That's understandable, but whatever alternative will be available to you, or to most people in that situation, at that point will probably be even worse anyway.

The most coherent decision to alleviate this would be more along the lines of 'maybe 95% of lifetime health expenditure shouldn't be poured into the last 3-4 years of low QALY living' as opposed to reworking the healthcare system. It's simply unsustainable to have the majority of people make it to their 80's after a long life of likely not even being an especially net contributor to the public purse.

That isn't a decision, it's a statement of the problem. What would you decide to do to alleviate this?

Given that I'd earn more as a nurse in the US than as a doctor in the UK, around triple for a traveling nurse.. Hmm

Nah. I'm still too proud to do that, even if 5 years of med school looks like a sunk cost at times. Besides, I don't think just being a doctor is sufficient credentials to work as a nurse in most places, and I'm not going through nursing school unless it takes like 6 months. I suppose most doctors don't end up in queer situations where that even remotely looks like a good idea.

Indian/South/SE Asian nurses have been propping up the profession for a while, during COVID, countries were falling over themselves to attract as many as they could get. The only reason more don't emigrate, at least from India, is because they're not fluent enough in English, even if in practise I don't think that would be too much of a hindrance if they can grokk the basics.

Man, fuck UK nurses, I thought the ones in government hospitals in India who wouldn't life a finger because of the comfort of their protected government jobs were bad. They're often trained to do trivial tasks like perform cannulations, catheterizations and so on there, but from a combination of stupid NHS trust policies that demand recertification and their own laziness, refuse to do so even when they're capable. It's easy for me to take for granted that work like this is done by the nurses at decent private hospitals in India, as well as the States, and I don't look forward to the inevitable dozens of cannulations I'll have to do daily as a doctor in the UK. My back hurts just thinking about it.

Most of this grunt stuff is below the level of a nurse in the USA- some of it is literally CNA(~6 week cert) work.

I don't imagine that extends to cannulations and the like does it?

The US has an extensive system of lower grade nurses and medical technicians/therapists that do a lot of that kind of stuff.

For things like washing soiled patients and such basic care, you don't need nurses. You need care assistants, who free up the nurses to look after the medical needs of the patients.

But this is like childcare; most people think it's too expensive, and after all how qualified do you really need to be to look after a few kids who aren't old enough for school yet?

Nursing homes and care centres need to pay good wages to attract staff; this means expensive prices; this means people can't or won't afford those prices. And as has been pointed out everywhere, for-profit private homes cut costs to the bone in order to maximise for shareholders or the owners of the homes. 'How qualified do you need to be to wash an old person or cook their meals?' and so they pay as little as they can get away with, which means hiring unqualified/immigrant/really low-quality labour; cut down staffing numbers; do everything to divert more profit to them.

So either people accept that a decent standard of care is going to be expensive; or such jobs are done on the minimum wage or under level (which means depending on immigrant labour); or governments and regulatory bodies can get serious about cracking down on the owners of homes which breach regulations and they can't just shut down, then open up a new place elsewhere.

All of that is difficult and will raise objections.

Even at minmum wage, 24/7 care is $5,580 per month (actually more with healthcare and Social Security contributions).

That's the problem. To earn a living if you're working as a care assistant, you need a certain level of wages. And then the home needs to cover all the other expenses, and turn a profit on top of that. So it's expensive to have paid care for the elderly.

But the days of "unmarried daughter lives at home to look after elderly parents" or "eldest son takes them into his home when he marries and they become dependent" are also gone, because most people do need to have two wages coming into the household, or they live far away from their parents, or they are too busy with their own lives. So some kind of paid care is needed.

And yet people still have the lingering views from the days when families took care of the older generations about "well how hard can it be to look after kids/old people, why is childcare/nursing home care so expensive?"

Unqualified labour, migrant labour, and hoping for robots to do care work is the idea for keeping costs down. How well does that work? Will we get care robots that can cope with handling humans? Who knows?

• (Related tidbit from outside this particular hearing: Senator Bill Cassidy, Bernie Sanders’ Republican counterpart on the Senate HELP Committee, has complained that we have a shortage of trained nurses partially because many states require nursing colleges to be taught by nurses with masters degrees, who are few in number and already mostly working as practitioners. I can buy this because in my experience looking into other healthcare issues, state level regulations often do make federal laws go much less far. For example pricing transparency rules don’t really matter when states allow hospitals to be monopolies.)

• Democrats responded that the rule provides $75 million in grants to train nurse aids, and also pointed out that Democrats repeatedly have tried to boost federal spending to help with this kind of training and hiring but Republicans were opposed soooo.

So the states restrict training more than is federally required and the response is to give them more federal money so the state can get out of the problem they caused? Seems wrong.

It does, but the Republicans, including Sen Cassidy, aren't proposing addressing state level restrictions either, so it's the only solution on the table at the moment. I don't know exactly how the grants will be distributed, but if they can raise wages for nursing college teaching positions, it can also be a way of luring more talent there.

Democrats responded that the rule provides $75 million in grants to train nurse aids, and also pointed out that Democrats repeatedly have tried to boost federal spending to help with this kind of training and hiring

This has become a universal pattern now. Democrats impose some destructive rule, "patch it" with a grant-writing process manipulated by their political allies, and mock anyone who has a problem with this.
The "inflation reduction act" that was just the "green new deal" with a post-it note over the title did this by the hundreds-of-billions. A new rule bans the sale of gas stoves over an arbitrary BTU (after vicious smearing of anyone who suggested this might be happening), but you can't complain because the Green Building Alliance has been given 200 billion to hand out to state and non-profit grant programs to create local grant programs to buy professional grant-writers free induction stoves.

In this case that 75 million is tiny compared to the actual scale of the problem, and will vanish into "training programs" for "increasing transgender awareness and expression in nursing home patients," mandated by "human rights councils."

It's the ultimate expression of manipulating procedural outcomes with complete political control over the economy and population.

Democrats impose some destructive rule

What rule are you talking about? State regs constraining supply are very much bipartisan. This is true for education requirements as well as for more obviously monopolistic rules like CON/COPA.

A new rule bans the sale of gas stoves over an arbitrary BTU (after vicious smearing of anyone who suggested this might be happening)

Oh that? Just the celebration parallax again. No one's trying to take your gas stove away, and besides, gas stoves are terrible and no one should be allowed to buy them.

Prior to her death last month, my grandmother spent about two years in a retirement home. They struggled with staffing constantly. I’m not even talking about technical employees giving care, though I’m sure they were hard to find too. I’m talking about cooks, cleaners, and receptionists.

Quality of service fluctuated noticeably. Each time someone quit, the remainder of the staff were more stressed, and the inhabitants were more cranky.

The overall impression was that wages weren’t keeping up. I think the management might have cut them mid-pandemic? Either way, they could not or would not afford to crank up wages. There were rent hikes, but old people are a strange customer base. While they have lots of sunk costs keeping them from moving, they are particularly inclined to raise hell when something goes poorly. Or to just ignore a rent increase—what are you going to do, sue them? I could easily see this become a death spiral if morale got low enough to push out new clients.

Thing is, I don’t know why this would be limited to elder care. Was there a particular reason—COVID restrictions, or some regulatory regime—pushing staff to other industries? Or does every service job in Dallas have a similar level of churn? Is this post going to start another fight about inflation and lived experience?

Since she passed, I haven’t spent much time at her apartment. I doubt that they’ve reached a happy equilibrium. There’s a complex web of rents and reputation pulling against wages and property taxes and material costs. In better days, maybe a vacancy in the kitchen was easy to fill. Today, if frictions really are higher, maybe that gap pulls everything else down with it.

I'm sorry to hear about your grandmother's passing.

Or does every service job in Dallas have a similar level of churn?

Yes. Dallas has a strong labor market coupled with high housing costs relative to low skill wages; the guy you find to drive in from waxahatchie or royse city to earn $14/hr instead of $12/hr will either find a better job or get arrested for driving in on a suspended license every day, and the local low skill laborers are getting squeezed out.

Was there a particular reason—COVID restrictions, or some regulatory regime—pushing staff to other industries?

Anecdotes are not data, but what I was hearing during the lockdown in Ireland was that a lot of the hospitality industry laid off staff and didn't guarantee that they would have jobs to come back to. So people got jobs elsewhere, then when the lockdown was lifted and the pubs, etc. were looking for staff back, people said "why would I work unsociable hours in crappy conditions for bad pay, when I have a better job now?"

Unless unemployment levels hit that point where any kind of a job is better than none, low-paying/poor conditions jobs are going to remain open since people can find work elsewhere. The retirement homes may not be able to pay more, or they may just not want to. Either way, if they can't make it worth people's while to work there, then staffing levels will be hit.

a lot of the hospitality industry laid off staff

But why would they do that? Genuine question.

Money saving measures. Understandable, if you're a pub or restaurant that now can't have more than X number of people inside and they have to be Y feet apart, and on top of that the public is being cautioned to stay at home and not go out in public. The custom isn't there, so the work isn't there and the money to keep people paid isn't there.

But some places instead of telling people "it's a temporary shut-down, there's a job for you when we re-open", just got rid of people (presumably expecting they could just hire new staff back when re-opening) in preference to temporary lay-off, then had trouble recruiting back post-pandemic. Because some workers had gone abroad, and some had gone into better jobs:

“It is estimated that around 20pc of the workforce in the travel and tourism industry left the sector permanently during the pandemic. Some left the country as they were laid off, and many sought employment in other sectors like construction which resumed trade earlier and some cases offered better remuneration.

“The sizeable gap in staffing has already caused substantial disruption for some businesses who have been forced to adjust their operating models and this could delay their recovery,” he said.

This has resulted in situations such as:

-Rooms in most hotels are only cleaned when requested by the customer
-Some hotels had to close down some bedrooms or lost on revenue because room could not be serviced
-Bars and restaurants reviewing their opening/closing times as allowed by staffing levels
-Reduced menu items

“In order to retain/maintain or secure new staff many hospitality businesses have resorted to increasing remuneration, which may have a longer-term impact on the sector unless businesses are able to pass the increased cost of business to their customers. The increase may also have to reflect the impact of inflation on food and beverage costs and utility expenses among others.

The hospitality industry is a long time situation of long and unsociable hours, low pay, being expected to do extra work, etc. Most places are good, but there are always the smaller, owner-run ones which do exploit staff (there's one such hotel in my home town which is notorious for this). This leads to constant turnover, poor service, etc. (hilariously, years back when one of my siblings got a summer job in a local hotel, they arrived in to work one morning to find the manager cooking the breakfast for guests because the chef had walked out).

It's a misunderstanding on my part then. I thought the original comment was about retirement home employees and hospital staff in general.

I think the way titles are used is also confusing; there's nursing staff and registered nurses and practical nurses, and different countries describe the jobs differently:

There are five levels of nursing: Certified Nursing Assistant (CNA), Licensed Practical Nurse (LPN), Registered Nurse (RN), Advanced Practice Registered Nurse (APRN), and Doctor of Nursing Practice (DNP). Each level has different requirements, educational qualifications, and salary rates.

So a speech or a newspaper article about "we need more nurses" could mean RNs or they could mean CNAs. Pretty much you are going to need more of everyone, but the ones helping patients bathe etc. aren't the RNs:

CERTIFIED NURSING ASSISTANT (CNA) Position description: Although a CNA is not an actual nurse, they’re the main line of communication between the patients and the nurses. CNAs typically take care of the patients’ hygiene, feeding, and mobility needs. With the help of CNAs, patients can bathe, eat, transfer from beds to wheelchairs, and perform other necessary daily activities.

Requirements: To become a CNA, the first thing you need is a high school diploma. Next, you’ll have to undergo a state-approved education program that lasts up to 8 weeks, with specific numbers of hours in the classroom or clinical practice. Last but not least, you’ll need to pass a CNA exam that tests all that you’ve learned and gives you the opportunity to start your life as a nurse.

Over here that would be a healthcare assistant or the likes, not a nurse, but Americans like fancy titles and steps up the salary ladder in an orderly progression 😁

What’s the Difference Between a Nurse and a Healthcare Assistant? While Nurses and Healthcare Assistants both care for patients, there are important differences in their roles. A Nurse is responsible for a patient’s medical care and has greater freedom when it comes to assessing and observing their health and condition. A Healthcare Assistant is involved in a patient’s basic, daily and personal care.

In Ireland, Nursing is a graduate career so involves extensive study. You don’t need to earn a degree to be a Healthcare Assistant – a QQI Level 5 qualification allows you to work in the role.

People still have the old-fashioned image of nurses in mind when they did change bedsheets and the rest of it, but now it's a much more technical role.

But why would they do that?

Because it was illegal for the vast majority of hospitality businesses to operate in anything resembling their normal form?

Can you elaborate please?

As you undoubtedly recall, operation of the vast majority of hospitality businesses was outright prohibited over the 2 years weeks to flatten the curve.

That means that those businesses no longer required the services of their staff. So they were (temporarily to permanently) fired without cause, which is what "laid off" means.

Thing is, I don’t know why this would be limited to elder care. Was there a particular reason—COVID restrictions, or some regulatory regime—pushing staff to other industries? Or does every service job in Dallas have a similar level of churn? Is this post going to start another fight about inflation and lived experience?

Anecdotally, many service jobs I encounter on a regular basis have gone downhill in the past few years post-Covid. I'm thinking particularly servers and cafe clerks, but also public transport drivers. It's not that their individual performance has gotten worse - AFAICT, that's remained the same - but they're constantly understaffed, leading to just inevitably terrible service due to the long wait times. This also causes extra stress on the staff, which sometimes results in less-than-ideal performance that would have been better but for the extra pressure put on them due to the reduced staff.

My pet theory is that the Covid lockdowns made a lot of people in the service industries realize that these jobs generally weren't worth the pay in comparison to other ways they could be spending their time, whether that be staying at home or pursuing some other venue to make money, resulting in a shortage relative to what the economy was used to before. Perhaps it's a bit of a market correction, where these workers, for whatever reason, were priced below their market price, and suddenly a lot of the workers realized this at once and, in an uncoordinated fashion, simultaneously decided to quit the industry.

I'd add that the 2021-22 period was also one of uncertainty for many service sector workers because governments promised that restrictions will be eased soon, but nobody knew if this'll last, or there'll be a policy reversal due to a new panic once the data arrives about supposedly growing COVID rates and whatnot. I'd assume many people decided that they can't just sit around waiting for times to get better sometime in the future, and left the sector.

My impression is that Covid was a signal for Boomers to retire. Now all those service jobs which used to be filled with Boomers are staffed by nobody, so labor is hard to find and more expensive. As a concrete example, an aquaintence was a nursing assistant and dropped from full-time to retired in May of 2020. They have since returned to work, but only around 4 hrs/wk, and only in 1-1 care for clients they like, rather than the more economically efficient (but more demanding) group care. Social security is paying about what they used to make; why would they subject themselves to the stressful job?

Might be even worse than that, if retirees freed up a whole cascade of jobs via promotion. There was absolutely a hiring flurry in my industry and I wonder if it attracted some lower-skill employees who’d otherwise have been finishing their vocational training.

This is exactly what happened with our local healthcare. Nurse past retirement age finally "retired," then took up private practice to fill the gaps left by the completely incompetent hospital district, now "retiring for real except for helping friends/whoever asks because she can't say no."

Competent boomers were absolutely doing all the actual work, and losing them is destroying the institutional knowledge of every industry.

We're seeing a similar thing in Seattle with jails and mental facilities. No one wants to work at these places, and for good reason.

As the ratio of invalids to capable adult sincreases, this problem seems like it will only get worse. As usual, the socialist solution accelerates the decline. We need to think about ways to reduce the cost of institutionalization, not increase it.

On a positive note, generative AI could be a boon for the elderly. The desperate loneliness felt by the old and infirm will soon be alleviated by convincing AI-generated video chats.

COVID sky money plus COVID restrictions meant it was often better to just stay at home and collect skybucks rather than go to work at a shitty job and lose said skybucks.

The Democratic response is infuriating. The way this is currently playing out is simple: people and families that would benefit from skilled nursing either get no care or, like a close relative of mine, spend weeks in a hospital (soon, months).

As an aside, this has increased my appreciation of the Fed and reduced my enthusiasm for keeping unemployment extremely low as a method of spreading prosperity.

So…what should the Democrats be doing? What should anyone in the federal government be doing, really?

If there really is a shortage of nurses, nothing we can do will take effect faster than a new crop goes through the school system. Well, except for lowering the bar to untrained care.

I agree, not much, but the federal government can definitely avoid exacerbating the problem by limiting supply.

We could make it eaiser for nurses to immigrate.

but also nursing homes genuinely don't seem to be the funds to hire the desperately needed more nurses, even though they were able to (at least moreso) only a few years ago?

Haven’t nursing salaries exploded in the past few years?

I mean obviously ‘they can’t do it, so mandate they do’ won’t fix… anything. But it’s not a mystery why there’s suddenly a lack of nurses in nursing homes.

I mean obviously ‘they can’t do it, so mandate they do’ won’t fix… anything. But it’s not a mystery why there’s suddenly a lack of nurses in nursing homes.

I'm not following. What's the reason there's suddenly a lack of nurses in nursing homes?

Nurses pay skyrocketed after Covid while supply shrank(due to pandemic related bullshit) and nursing homes had always been at the low end of the pay scale due to relatively poor funding.

Better pay elsewhere.

That nursing homes can’t afford them. Or enough of them.

Lovely that the Democrats respond to a supply crunch by further increasing demand via these new rules.

Was the idea of raising wages discussed? Politicians tend to think of workers as a fixed number that meet the requirements but in reality the number who would be willing to work this job depends on the wage. How many "qualified" people are just doing more pleasant things with their life right now?

If there truly are not enough workers who meet the legal requirements, then maybe the law should be changed to stop limiting supply. The federal government could make a "shall issue" style law for getting qualified as a caregiver. Or leave it up to facilities and customers to negotiate the level of training they require.

Lovely that the Democrats respond to a supply crunch by further increasing demand via these new rules.

Governments love to restrict supply and subsidize demand. They are basically helpless to solve supply crunches.

Governments love to restrict supply and subsidize demand

Why is that?

Restricting supply is the tools of the trade, regulation and taxation. It is often easier to tax the supplier then it is to tax the consumer.

Subsidizing demand is popular and offering to do it wins elections.

Simplistically I think it comes down to empathy versus brutal neoliberalism. There is always some interest group losing to market forces so they care about them and do something to help them but it then restricts supply.

When all you have are taxes and subsidies, everything looks like a... a thing you tax and subsidize.

See in the OP where the response to lack of nurses available to train other nurses is that we'll spend $75 million on it.

Wages aren't enough to get people to do working class jobs. People will rather make less working as a journalist than work as a plumber. Being a social media strategist or HR will be more attractive than changing diapers and driving trucks. Unless they want to pay wages that are well out of the realm of possibility for content writers it isn't going to work.

The most effective method to get more nurses would be to fire communications majors from government jobs. A sizeable portion of the upper working class and the fallouts of the actual middle class no longer do working class jobs. Instead they get degrees in less demanding subjects from lower tier colleges. The meme of them becoming baristas isn't accurate. Most of them do get office work. However, they would be far more productive welding, building and caring.

It's fundamentally a recruiting that could be addressed the way the federal government addresses other recruiting shortfalls: cash bonuses, educational loan forgiveness, or even just direct educational subsidy. There's no reason you couldn't have a nursing equivalent of Teach for America or even ROTC.

There's no reason you couldn't have a nursing equivalent of Teach for America or even ROTC.

Have these been great successes? Because from where I sit we also have a shortage of quality teachers and military officers. Do elite schools even have ROTC anymore? Sometimes, after a late night out I would see them on campus in their uniforms. I pitied the poor bastards.

There are 58,500 “news analysts, reporters and journalists” vs. 520,700 plumbers and pipe fitters. It sure doesn’t seem like plumbing is that unpopular, to say nothing about the millions of other blue-collar jobs.

If you fire all 826,200 “media and communications workers,” you might be getting somewhere. How many of them do you think are working for the government?

Source

Tough to find data at my fingertips, but I've heard that the non-profit sector, which is largely unproductive, has grown from approximately 0% to 10% of the workforce in the last 50 years.

The noisy bit of the non-profit sector is unproductive. But the big numbers in non-profit employment are in service provision in fee-charging or government-contracted non-profits - the most visible examples are church and university-owned hospitals; private, parochial and charter schools; and private universities.

Government-contracted non-profits have essentially the same problems as government-contracted for-profits. Fee-charging non-profits like university-owned hospitals are notoriously run in exactly the same way as for-profits, including the "sometimes making huge profits" bit. In general, I would say that service-providing non-profits are only unproductive in a Sturgeon's law kind of way which also applies to the for-profit and government sectors.

But the big numbers in non-profit employment are in service provision in fee-charging or government-contracted non-profits - the most visible examples are church and university-owned hospitals; private, parochial and charter schools; and private universities.

I guess we'll have to see the numbers. I agree that those institutions are productive, or at least no worse than private or government alternatives.

I do wonder how many people are in the activism and awareness space. I seem to come across a lot of them in my personal life. I try not to wince when they tell me what they do.

Top 10 registered UK charities based on paid employee headcount - not sure how I would find the equivalent for the US. Registration is optional for universities which is why they don't dominate the list.

  • SAVE THE CHILDREN INTERNATIONAL 18409 - Fundraises from the public, mostly doing foreign aid stuff. Some advocacy work, but not as much as, say, Oxfam, so most of the staff are on direct work.
  • NUFFIELD HEALTH 17165 - Fee-charging non-profit which operates a chain of private hospitals and a chain of gyms.
  • THE BRITISH COUNCIL 9861 - About 1/2 of the budget is language schools (fee-charging with some UK government subsidy) and 1/4 is handing out scholarships for overseas students at UK universities (ultimately UK government funded). The other 1/4 is annoying nonprofit stuff.
  • THE HALO TRUST 9741 - Removes landmines on UK and foreign government contracts
  • United Learning LTD 9144 - Runs charter schools, mostly on UK government contracts
  • MSI REPRODUCTIVE CHOICES 8993 - Runs sexual health clinics in 37 countries - funding is a mix of UK and foreign government contracts and fee charging.
  • ROYAL MENCAP SOCIETY 8009 - Does some fundraising and advocacy, but about 80% of the budget is providing mental health services under UK government contracts
  • BARNARDO'S 7317 - About 1/2 of what it does is running childrens' homes under UK government contracts, the other 1/2 is advocacy.
  • THE NATIONAL TRUST FOR PLACES OF HISTORIC INTEREST OR NATURAL BEAUTY 6651 - Operates a range of heritage attractions (particularly famous for the stately homes and the trailhead carparks in the UK national parks), mostly funded by admission fees. Has an advocacy arm which makes a lot of noise on a tiny budget because it has become a kind of clearinghouse for wealthy retired NIMBY Karens.
  • CARDIFF UNIVERSITY 6032 - Does what it says on the tin.

So I would say across these 10 names 20% of the activity is annoying nonprofit stuff and 80% is providing services on a commercial or government-contract basis. My guess is that the US figures would be even more skewed because of the large number of nonprofit-owned hospitals in the US.

There is a lot more creativity in job titles when it comes to various low productivity office jobs. Tradesmen tend to have short and to the point titles. The people who should be in the trades tend to have vague titles.

Umm, have you run this thesis by actual tradesmen?

From my vantage point most bs office jobs are going to people who would have been housewives or secretaries in an era when the trades were fully staffed, and the trade shortage is as much about having to compete with IT and relatively earlier retirements making the fertility crunch apparent earlier, and that while there’s a minority of men who should be working trades jobs in offices, they mostly have actual jobs that either would have existed in 1960 or exist now because of an actual function. Most young men who should go into a trade seem like they’re playing video games and smoking weed instead, funded by some combination of parents/neetbux/McDonald’s. Likewise trades job titles are increasingly unwieldy; everyone is a ‘technician’ these days.

I don’t believe titles came into this.

How many communications majors do you think are in government jobs?

Was the idea of raising wages discussed?

Yeah, this was the crux of the side debate, where Democrats pointed out in the past they've tried to pass greater funding to allow for raises, but Republicans have been opposed. The rule that 80% of federal funds must go to direct workforce is also an atetmpt to ensure that wages are prioritized, if not having raises literally mandated.

If there truly are not enough workers who meet the legal requirements, then maybe the law should be changed to stop limiting supply. The federal government could make a "shall issue" style law for getting qualified as a caregiver.

I think this would be ideal, but both Democrats and Republicans are less likely to pass laws that are seen as targeting state level regulations in absence of a very compelling reason. It happens of course, but getting a serious majority on board with removing a masters degree requirements for specific industries for twenty seven states or whatever is a harder legislative sell than just passing funding laws or regulations that aren't directly challenging state govs. Significantly, this wasn't even discussed by either party in the hearing, I've just happened to hear Senator Cassidy say it in another context.

Or leave it up to facilities and customers to negotiate the level of training they require.

Training and cert requirements are also mostly handled by state law so unfortunately there isn't a ton of room to directly negotiate for providers.

The rule that 80% of federal funds must go to direct workforce is also an attempt to ensure that wages are prioritized, if not having raises literally mandated.

But the side effect is that technology that reduces the workload of nurses is discouraged, since you run into problems if you spend money on technology, rather than nurses. Thus making the nurse shortage worse.

Fair point

I think this would be ideal, but both Democrats and Republicans are less likely to pass laws that are seen as targeting state level regulations in absence of a very compelling reason. It happens of course, but getting a serious majority on board with removing a masters degree requirements for specific industries for twenty seven states or whatever is a harder legislative sell than just passing funding laws or regulations that aren't directly challenging state govs. Significantly, this wasn't even discussed by either party in the hearing, I've just happened to hear Senator Cassidy say it in another context.

They should just go all the way and remove the ability of states to create licensing requirements for jobs. It was a nice little experiment while it lasted, giving every last petty tyrant in every industry the right to restrict their own competition. But it has two inevitable outcomes, worker shortages and price increases for consumers. Allow states to set up certification systems, but do not allow them to restrict what work can be done by whom.

Of course it takes a crisis in geriatric care to get the geriatrics in congress to notice this massive blunder.

I'm in favor. It would be a pretty massive move away from federalism and towards centralization, so I imagine it would be hard to pass though.

Of course it takes a crisis in geriatric care to get the geriatrics in congress to notice this massive blunder.

You seem optimistic and assume they notice actual problem

They are noticing a worker shortage in geriatric care. There has been a shortage of medical personnel for a while.

I suspect they may be noticing evilness and bizarre uncooperativeness of nursing homes operators, utterly without connecting it to worker shortage or guild system causing it.

everyone in both parties agrees that we have a critical lack of workers in nursing homes

are they agreeing that it is caused by shortage of such workers?

Yeah, the hearing the OP was from focused on a shortage of workers in nursing homes. There were a few people who ran nursing home systems as witnesses, no one suggested they or anyone else were evil or uncooperative.

Is it a blunder if such policy would be unconstitutional?

“Interstate commerce” may be pretty tortured, but license to practice within state borders is certainly not a central example. I’m not sure you could destroy the state ability to regulate work without also destroying its ability to regulate…anything.

Forbidding protectionist licensing schemes seems squarely within the Dormant Commerce Clause powers of the federal government:

The Dormant Commerce Clause, or Negative Commerce Clause, in American constitutional law, is a legal doctrine that courts in the United States have inferred from the Commerce Clause in Article I of the US Constitution.[1] The primary focus of the doctrine is barring state protectionism. The Dormant Commerce Clause is used to prohibit state legislation that discriminates against, or unduly burdens, interstate or international commerce. Courts first determine whether a state regulation discriminates on its face against interstate commerce or whether it has the purpose or effect of discriminating against interstate commerce. If the statute is discriminatory, the state has the burden to justify both the local benefits flowing from the statute and to show the state has no other means of advancing the legitimate local purpose.

For example, it is lawful for Michigan to require food labels that specifically identify certain animal parts, if they are present in the product, because the state law applies to food produced in Michigan as well as food imported from other states and foreign countries; the state law would violate the Commerce Clause if it applied only to imported food or if it was otherwise found to favor domestic over imported products. Likewise, California law requires milk sold to contain a certain percentage of milk solids that federal law does not require, which is allowed under the Dormant Commerce Clause doctrine because California's stricter requirements apply equally to California-produced milk and imported milk and so does not discriminate against or inappropriately burden interstate commerce.[2]

The question becomes whether states have a legitimate compelling interest in having separate regulatory regimes, even if they have fundamentally the same actual standards. I would think not. States could probably carve themselves out some exemption in cases where they demonstrate materially different working requirements though.

Thanks for linking this, that was useful to know the exact way the law could apply to state licensing regimes.

Congress has multiple levers for encouraging state compliance. But no, none of this is really constitutional.

The political solution should be at the state level, but if congress is going to keep insisting on messing with medical care at the national level I don't see how this is much different.

Was the idea of raising wages discussed?

wait, are nursing homes operated in USA by state? or by private companies?

(also, raising wages will raise costs of this facilities...)

lifting the supply restrictions on nursing colleges

wait, is there medieval-guild style limit on how many people can enter profession? And it was not raised despite massive supply issues? Not even proposed to be raised by someone?

I guess that noone actually wants to solve any problems here.

Yeah, welcome to the world of the American medical system, where the opening of a healthcare facility is dictated by their competition and medical licensure is effectively controlled by a cartel. I'm sure a more market-based system wouldn't be a panacea, but people claiming that American medical prices suck because it's a market-based system are not addressing the system that actually exists.

I'm sure a more market-based system wouldn't be a panacea

It might not be a panacea, but it could work really well. The prices at the Oklahoma Surgery Center, for example, are often 50-90% less than comparable surgeries at a non-free-market hospital.

Check out the transparent prices!

https://surgerycenterok.com/surgery-prices/

We don't need to necessarily eliminate the current system, but we should over time stop subsidizing it in favor of more places like the Oklahoma Surgery Center.

American medical system is truly fractal of a bad design, managing to combine some worst aspects of free market, government institutions and universities.

I was aware that it is not some free market system and far away from that but I am still getting surprised.

Though if supply is restricted then free market "Was the idea of raising wages discussed?" will not really help. Unless many people go to supply restricted medical school then work in other professions or do not work at all?

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