Of all the terms that have been redefined during the past two years, perhaps none has undergone more change than “disaster.” The definition has been stretched in nearly every direction possible. Tasks like business travel that might have seemed normal before prolonged isolation and lockdown are now described as unbearable ordeals; weeks where only 900 Covid patients die per day are tolerable.
Our response to “disaster” has also changed as Covid has revealed whose crises matter and whose do not. In the early months of the pandemic, when the public learned about thousands of deaths in understaffed and poorly run nursing homes around the country, an optimist might have expected extensive and immediate change to that industry. Even though New York Assemblyman Ron Kim went on a crusade against former governor Andrew Cuomo for putting Covid patients in nursing homes and then covering up many of their deaths, there was not a sense of political emergency.
February brought some hope of reform when the Biden administration released a plan that called for a broad set of improvements, including mandating nurse staffing minimums and beefing up penalties against delinquent institutions. The administration also criticized the “dangerous” trend of private equity firms increasing their investment in the industry from $5 billion in 2000 to more than $100 billion in 2018.
Last week, the National Academies of Sciences, Engineering and Medicine published a nearly 600-page report arguing for comprehensive changes to the industry. Their suggestions include the construction of smaller facilities that would more closely resemble family homes, revamping the ways that both Medicaid and Medicare fund elder care and, perhaps most important, a fundamental change in the way we think of labor.
Low-level-care nursing home workers, sometimes disparagingly referred to as butt-wipers, are poorly paid and trained, and seen as expendable. The paper suggests that better pay, benefits and training will bring stability and dignity to this kind of work.
As smart as these suggestions are, we all know that plans in reports and papers often never escape the page, especially when they’re up against big for-profit industries. This also isn’t the first time the federal government has called for wide-scale changes to fix elder care. In 1986, the National Academy of Medicine published a report calling for similar reform. That was followed by a comprehensive 1987 legislative package that established a nursing home bill of rights.
Why didn’t these efforts in the 1980s lead to sustained changes in nursing homes? There were certainly some improvements after the 1987 bill, but how did conditions in elder care get so bad again? And how do we ensure it’ll be different this time? To find out, I spoke to Betty Ferrell, a palliative care expert and the chair of the committee that authored the recent paper. Our conversation has been edited and condensed for clarity.
Why didn’t the 1987 bill solve these problems? It feels like we are reliving that moment in some ways.
Mostly, it didn’t solve this problem because there weren’t enough resources put into this and there was little reinforcement. We can say that there needs to be a registered nurse in a facility 24 hours a day, or there need to be minimum staffing requirements. But then if states don’t have funding to have regulators that go out and survey those nursing homes, and if there’s not reinforcement in place if those things don’t happen, and there’s not been enough funding for ombudsman programs — there are just so many things, where, yes, there are rules on the books, but we haven’t reinforced those rules. And so as a result, there’s terrible care. A huge starting point is reinforcing the regulations that are already on the books, having people going in and inspecting these nursing homes, and then taking action, not letting people continue to operate until they fix the problem.
Two-thirds of nursing homes are for-profit. So the owner of a facility that’s not meeting the requirements and is providing really inadequate care can go across town and build another facility and provide the same inadequate care. So shouldn’t we have regulations that would say, if you can’t even run one nursing home, why would we let you build other nursing homes?
Do you think it’ll be different this time?
Yes, I do. We have an aging society. A lot of people are living long enough to totally exhaust their family caregivers. The reality is that if someone is diagnosed with a serious illness, who’s going to take care of them? Their elderly spouse, who by the way has prostate cancer and diabetes and hypertension and dementia? And I think finally addressing the nursing home issue is one part of addressing how we as a nation are going to care for our aging population.
A large portion of your paper is about labor conditions for nurses and other care providers. What does a well-compensated, well-trained and well-run nursing home staff look like?
There are places that are providing good care and have well-compensated, well-trained staff, and so we know it can be done. We have this circumstance where you can make more money working at McDonald’s than you can working at a nursing home. Not that people at McDonald’s don’t work hard, but compared with working in a nursing home, where you’re dealing with the challenges of working with people who are seriously ill, it’s a tough job. And many staffs in nursing homes are working two full-time jobs just to try to survive. These are people who are making $10, $12 an hour — that’s like $20,000 to $28,000 a year. So nursing home staffs are exhausted, they’re working two jobs, and they’re not at all well compensated for their work.
The other problem with that is, if you’re a nursing assistant and you’ve been working for $10 an hour, and the desperate nursing home down the street offers you $10.50, you’re probably going to change jobs. So in many nursing homes, there’s over 100 percent turnover each year. And so, again, how do you possibly provide good care when the staff is always changing? So back to your question, a good nursing home looks like a place where staffs are paid a fair wage. And so you attract a higher level of staff, and the staff stay there.
And then when it comes to safety and training, it’s basic issues. It’s basic skin care, safety precautions and so on that were just so absent during Covid, which is why cases were just rampant in nursing homes, because these nursing assistants and other staff weren’t trained in basic infection control precautions.
We need a higher level of staffing in nursing homes to deliver the basic care. And that won’t happen until we start paying them well, until we provide them with education, until we support them.
Do you think meaningful change is possible without an overhaul of the private sector and for-profit/chain nursing homes?
No, absolutely not. The way the U.S. finances, delivers and regulates care in nursing homes is ineffective, inefficient, fragmented and unsustainable.
A lot of public money is going into nursing homes, but there’s no transparency about how those nursing homes are spending taxpayers’ money, or how much of it is going to the nursing home owner because he owns the building and is paying himself a very high rent. In our recommendations, we were very clear that there has to be transparency, that if you’re about to put your mother in a nursing home, you need to know who owns this nursing home and how much of the $7,000-a-month check you’re writing is going toward care for your mother. So we think the whole system is broken.
There’s nothing I’ve reported on that makes me feel more hopeless than elder care — we had hundreds of thousands of people die in these facilities, and yet it seems a lot of people want to sweep all this under the rug. Do you think the public will want to undertake the massive project you and your co-authors are envisioning?
Most people don’t think about nursing homes, and most people don’t go to nursing homes until it’s their moment in time where suddenly their parent is there. And it’s a for-profit industry that has not had enough oversight and regulation, and it has not had any level of transparency. For the nursing home industry to continue as it is now — being able to profit in such a significant way without providing quality care — is outrageous. I don’t think we can look away any longer.
We’ve issued our report. We put it in the hands of policymakers. And it is going to take public pressure to get all the right forces to do the right thing. We have hit the point where it’s undeniable, and we have to act.
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Jay Caspian Kang (@jaycaspiankang), a writer for Opinion and The New York Times Magazine, is the author of “The Loneliest Americans.”