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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.
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.
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.
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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.
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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.
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