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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.
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:
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.
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