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PaperclipPerfector  6mo ago (text post)   24882 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.

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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