COVID Crisis in Long Term Care Who Is to Blame?
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Get instant access to members-only products and hundreds of discounts, a free second membership, and a subscription to AARP the Magazine. Experts foresee a similar reckoning for what has been happening in America’s nursing homes during the . Yes, they say, fingers can and should be pointed at how elected officials, regulators, owners and others responded to the crisis. But the American nursing home industry exists as it does today because of federal laws and regulations that go back 85 years. The infrastructure these laws created, no matter how well intended, didn’t anticipate the future, nor could it foresee a health storm of this magnitude, speed and deadliness. To fully understand the underlying causes of the nursing home debacle of the past nine months, AARP spoke with dozens of experts, from scientists and researchers to historians, doctors, nursing home staff and industry heads. The interviews revealed large and small mistakes made at every level, from the federal government to states, local health departments and individual nursing homes. Here’s what they told us.
But even more influential to the industry was the creation of and Medicaid in 1965. Medicare, the federal health insurance program for individuals 65-plus, was set up to pay for doctor and hospital visits as well as short-term stays in nursing homes. But Medicaid, which covers primarily the poor, and is funded by matching state and federal funds, became the payer for long-term care in nursing homes. Before the launch of Medicare and Medicaid, few families struggled to pay for nursing home care, says Bruce Vladeck, an expert on nursing home policy who in the mid-1990s was the administrator of the federal agency that directed Medicaid and Medicare. Back then, nursing home care was relatively inexpensive, he says. And few people lived long enough to require it. But as life expectancy grew dramatically in the last half of the 20th century, so did the cost of medical care and nursing homes. That created the financial hardship many middle-
class Americans face today. “The great takeoff in health care prices in this country didn’t start until the early ’60s,” Vladeck says. The Medicaid entitlement, critics say, is most responsible for the nursing home industry we have today. Although multiple studies and surveys show that few older people would choose to live in nursing homes, such facilities have become the only viable option for those who can no longer live in their homes without paid help. Under law, states are required to pay for nursing home care for anyone who qualifies. States are not required to pay for the home- and community-based services that would help seniors stay in their homes. If a state wishes to provide these services, it can apply for a waiver from the federal government. Even if approved, many waivers have enrollment caps. And in some cases, waiting lists for those wanting Medicaid-covered home care are so long that people die waiting. Making nursing homes the de facto choice for older Americans in need of care set the stage for the ravages of the pandemic, says Patricia McGinnis, executive director of California Advocates for Nursing Home Reform. “Nursing homes are not good places for anyone except for short-term rehab,” McGinnis says. “I would hope this is a wake-up call that the system isn’t working.”
It wasn’t until May that , M.D., a senior federal health official who has helped guide the pandemic response, asked governors to find a way to test all nursing home residents and workers in their states. But implementation was left up to states, and governors scrambled to purchase tests that were in short supply. Maryland, in April, imported supplies from South Korea, while other states failed to find tests at all. By midsummer, rapid-response tests became more available, yet many nursing homes had still not begun testing residents or staff and some still struggled to get tests. CMS finally required nursing homes to in September. By then, the damage had been done. Even at that late date, some nursing homes were still experiencing test shortages and in some cases could not receive lab test results within a week. Without widespread testing, efforts to stop the spread were doomed, Katz says. Unlike many nursing homes, Johns Hopkins, one of the top medical institutions in the world, had both coronavirus tests and a lab to quickly turn around results. After the Kirkland outbreak, Hopkins administrators charged Katz with developing a testing plan to help support Baltimore nursing homes. The plan wasn’t purely altruistic. Administrators worried that sick nursing home residents would soon flood the hospital’s emergency rooms. “Nobody wants an entire nursing home walking into your hospital at 2 a.m. with COVID,” Katz says. What Katz found astounded her. At the first nursing homes tested, more than 38 percent of residents were positive for the virus, and the majority of them had not shown symptoms, a finding with dangerous implications across the country, Katz says. The Johns Hopkins plan was a small-scale success. But the widespread testing that could have blunted the force of the pandemic did not happen early enough in most nursing homes. Researchers like Katz are often reluctant to draw strong conclusions from their work, preferring to let the science and the data speak for themselves. But on the federal testing initiative at nursing homes, she has harsh words. “The entire testing process in this country has been a complete debacle,” Katz says.
Who s to Blame for the 100 000 COVID Dead in Long-Term Care
Finger-pointing in wake of health disaster is widespread but causes were laid decades ago
Photo by Isadora Kosofsky To understand who or what is to blame for the more than 100,000 deaths caused by the coronavirus among residents and staff of U.S. long-term care facilities between March and Thanksgiving, it’s useful to consider a devastating calamity that hit in 2005: Hurricane Katrina. In the days, weeks and months after New Orleans was overwhelmed with flooding from the hurricane, critics pointed to the slow response from the federal government, decisions made by the city’s mayor and the state’s governor, a delay in engagement from the U.S. president, the greed and influence of private businesses, and even the stubbornness of the city’s residents as the causes for all the pain that had occurred. And many of the charges had some level of truth. But in time, two simple but profound causes were ultimately found to be the root of what happened: bad infrastructure decisions that dated back decades—in New Orleans’ case, a poorly maintained, inadequate levee system — and a storm of such magnitude that once 23 of the levees were breached, little could be done to prevent 80 percent of the city from going underwater.Get instant access to members-only products and hundreds of discounts, a free second membership, and a subscription to AARP the Magazine. Experts foresee a similar reckoning for what has been happening in America’s nursing homes during the . Yes, they say, fingers can and should be pointed at how elected officials, regulators, owners and others responded to the crisis. But the American nursing home industry exists as it does today because of federal laws and regulations that go back 85 years. The infrastructure these laws created, no matter how well intended, didn’t anticipate the future, nor could it foresee a health storm of this magnitude, speed and deadliness. To fully understand the underlying causes of the nursing home debacle of the past nine months, AARP spoke with dozens of experts, from scientists and researchers to historians, doctors, nursing home staff and industry heads. The interviews revealed large and small mistakes made at every level, from the federal government to states, local health departments and individual nursing homes. Here’s what they told us.
AT FAULT
Outdated Laws
1950s laws led to hospital-like settings for most nursing homes1960s laws ultimately made nursing homes reliant on government fundingMedicaid rules force many into nursing homes against their desires “Look at it from the 30,000-foot level,” says Eric Carlson, an attorney at Justice in Aging, who testified before Congress in June on the impact of the virus on nursing homes. “If you are living in a world with potential for pandemic, which we are, it seems like bad practice to put 150 people in their 80s together in tight quarters, two to a room, sleeping 4 feet away from each other. That’s about the worst thing you can do.” Yet that’s precisely what federal laws governing America’s more than 15,000 nursing homes have led us to. In fact, the law that created Social Security back in 1935 planted the seeds. In an attempt to keep older Americans out of public poorhouses, the Social Security Act prohibited payments to residents of public institutions; that helped launch the rise of private nursing homes. The residents in this long-term care facility share a room similar to those found in hospitals. Photo by Isadora Kosofsky The next law with a major influence on today’s came in 1954. The Hill-Burton Act, which funded hospital construction, was expanded that year to provide loans and grants to build nursing homes that agreed to provide low-cost care. The law instituted the medical model of nursing homes, in which older adults are housed in institutions that resemble hospitals more than, say, a college dorm or apartment. It’s a model that carries on today.But even more influential to the industry was the creation of and Medicaid in 1965. Medicare, the federal health insurance program for individuals 65-plus, was set up to pay for doctor and hospital visits as well as short-term stays in nursing homes. But Medicaid, which covers primarily the poor, and is funded by matching state and federal funds, became the payer for long-term care in nursing homes. Before the launch of Medicare and Medicaid, few families struggled to pay for nursing home care, says Bruce Vladeck, an expert on nursing home policy who in the mid-1990s was the administrator of the federal agency that directed Medicaid and Medicare. Back then, nursing home care was relatively inexpensive, he says. And few people lived long enough to require it. But as life expectancy grew dramatically in the last half of the 20th century, so did the cost of medical care and nursing homes. That created the financial hardship many middle-
class Americans face today. “The great takeoff in health care prices in this country didn’t start until the early ’60s,” Vladeck says. The Medicaid entitlement, critics say, is most responsible for the nursing home industry we have today. Although multiple studies and surveys show that few older people would choose to live in nursing homes, such facilities have become the only viable option for those who can no longer live in their homes without paid help. Under law, states are required to pay for nursing home care for anyone who qualifies. States are not required to pay for the home- and community-based services that would help seniors stay in their homes. If a state wishes to provide these services, it can apply for a waiver from the federal government. Even if approved, many waivers have enrollment caps. And in some cases, waiting lists for those wanting Medicaid-covered home care are so long that people die waiting. Making nursing homes the de facto choice for older Americans in need of care set the stage for the ravages of the pandemic, says Patricia McGinnis, executive director of California Advocates for Nursing Home Reform. “Nursing homes are not good places for anyone except for short-term rehab,” McGinnis says. “I would hope this is a wake-up call that the system isn’t working.”
AT FAULT
Government officials
Early pandemic decisions deprioritized nursing homesMonths of limited testing let the virus go unchecked continued to spread the virus throughout the facilities. Entertainment $3 off popcorn and soft drink combos See more Entertainment offers > “Nursing homes were left chasing their tails,” says Morgan Katz, M.D., an infectious disease expert at Johns Hopkins University School of Medicine who specializes in infection control in long-term care facilities. The Life Care Center of Kirkland became a hotspot for the spread of COVID-19 in the Spring of 2020. David Ryder/Getty Images In late February, the virus was first detected at Life Care Center of Kirkland, a nursing home in a Seattle suburb, which saw 37 deaths within a four-week span. The Kirkland case should have been a clear warning that nursing homes were at risk for outbreaks. In response, the (CMS) directed nursing homes to ban visitors and nonessential personnel and to restrict communal activities of residents. But no recommendation was made to do more rigorous testing for the virus.It wasn’t until May that , M.D., a senior federal health official who has helped guide the pandemic response, asked governors to find a way to test all nursing home residents and workers in their states. But implementation was left up to states, and governors scrambled to purchase tests that were in short supply. Maryland, in April, imported supplies from South Korea, while other states failed to find tests at all. By midsummer, rapid-response tests became more available, yet many nursing homes had still not begun testing residents or staff and some still struggled to get tests. CMS finally required nursing homes to in September. By then, the damage had been done. Even at that late date, some nursing homes were still experiencing test shortages and in some cases could not receive lab test results within a week. Without widespread testing, efforts to stop the spread were doomed, Katz says. Unlike many nursing homes, Johns Hopkins, one of the top medical institutions in the world, had both coronavirus tests and a lab to quickly turn around results. After the Kirkland outbreak, Hopkins administrators charged Katz with developing a testing plan to help support Baltimore nursing homes. The plan wasn’t purely altruistic. Administrators worried that sick nursing home residents would soon flood the hospital’s emergency rooms. “Nobody wants an entire nursing home walking into your hospital at 2 a.m. with COVID,” Katz says. What Katz found astounded her. At the first nursing homes tested, more than 38 percent of residents were positive for the virus, and the majority of them had not shown symptoms, a finding with dangerous implications across the country, Katz says. The Johns Hopkins plan was a small-scale success. But the widespread testing that could have blunted the force of the pandemic did not happen early enough in most nursing homes. Researchers like Katz are often reluctant to draw strong conclusions from their work, preferring to let the science and the data speak for themselves. But on the federal testing initiative at nursing homes, she has harsh words. “The entire testing process in this country has been a complete debacle,” Katz says.