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Notes -
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.
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.
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We could make it eaiser for nurses to immigrate.
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