SERIES: COVID-19’s Long-Term Policy Implications - COVID-19’s Impact on Nursing Homes and Long-Term Care Facilities
The COVID-19 pandemic has rightly become the sole focus of the public health policy world, but it is also having far reaching effects into policy landscapes way beyond healthcare. This blog post is the twelfth in a series that will explore how COVID-19 is changing American life, and as a result, impacting various policy areas. This series will explore changing American attitudes, examine new policy ideas, and project on legislative and regulatory activity we may see as a result of the virus in the months ahead.
We have long known that people 65 and older have the highest risk of dying from the coronavirus, and we have seen outbreaks become rampant in nursing homes and long-term care facilities. This has created anxiety for seniors and their families across the country, but only recently is the full picture of the coronavirus’s toll on U.S. nursing homes becoming clear.
A Vulnerable Population
On June 4, the Centers for Medicare & Medicaid Services (CMS) released a database showing 32,000 nursing home residents have died from coronavirus. At least 700 nursing home employees have also died. This figure is expected to increase, as 12 percent of all facilities yet to report their totals. Analysis from the New York Times paints an even more sober picture. They reported that 54,000 nursing home residents have died, representing 43 percent of all coronavirus fatalities in the U.S. In addition, in 24 states the majority of fatalities come from nursing homes and long-term care facilities.
For the first few months of the pandemic, information about nursing home cases and deaths was hard to come by. Several dozen states refused to make the information public, leading to lawsuits across the country. On April 30, CMS published a rule requiring nursing facilities to report information not only on cases and deaths but also equipment and staffing shortages.
According to the database created by CMS, nearly 2,000 facilities reported insufficient nursing staff and more than 2,200 said they lack enough surgical aides. More than 500 said they don’t have any N95 masks, and more than 250 said they don’t have any masks at all. While the Department of Health and Human Services (HHS) has allocated $4.9 billion for personal protective equipment (PPE), advocates say this falls short of what is needed.
The grim reality of the pandemic’s impact on our nation’s nursing homes is causing many residents and their families to consider alternatives. From “granny flats”—small units built in backyards, above garages, or in basements—to multigenerational living, alternatives to nursing homes were already growing in popularity prior to the pandemic. COVID-19 could increase these trends over the long-term.
A Lack of Oversight
According to data released by CMS, only a little more than half of the nation’s nursing homes have been inspected for staff compliance with procedures to prevent coronavirus transmission. In response, CMS Administrator Seema Verma issued a new mandate compelling states to complete these investigations by July 31 or risk losing federal recovery funds.
Oversight can be complicated. Many officials from states that were hit hard by the virus say they only had enough funds for either PPE for frontline health workers or inspectors and were forced to choose the former. The lack of safety equipment has delayed in-person checks for weeks, if not months. As an alternative, some states chose to assess facilities remotely, conducting interviews over the phone and analyzing documentation, a process many experts consider inadequate.
In states where officials have said that in-person inspections have taken place, the associated reports have found no issues in the overwhelming majority of cases. A recent analysis of these reports found that less than three percent of the more than 5,700 inspection surveys the federal government released this month had any infection control deficiencies. Experts say this is just not possible or believable given the infection and death rates observed in these facilities.
Additionally, many states imposed restrictions on family members visiting their relatives in nursing homes and long-term care facilities. Although this policy was well-intended to prevent the virus from entering the facility, it appears to have been ineffective in curbing infection rates. Additionally, prohibitions on family visits have removed another source of accountability.
The Congressional Response
The Health and Economic Recovery Omnibus Emergency Solutions (HEROES) Act, which passed the House on May 15, includes several provisions aimed at assisting nursing homes. Though the HEROES Act represents only House Democrats’ opening position in negotiations, this bill:
Provides $150 million for the deployment of expert strike teams to nursing homes struggling with COVID-19 cases;
Mandates transparency and demographic-specific reporting of COVID-19 cases, fatalities, and other essential data;
Prioritizes testing for older Americans and individuals with disabilities;
Enhances the ability of nursing home residents to virtually connect with their loves ones; and
Creates new, COVID-19-only facilities with criteria that prioritize resident safety.
At this point, we anticipate negotiations on the next COVID-19 package will begin in earnest after July 4. Senate Majority Leader Mitch McConnell (R-KY), who has been reluctant to initiate negotiations on another relief package, has recently suggested another COVID bill could pass Congress in late July.
The House’s Select Subcommittee on the Coronavirus Crisis launched a probe on June 16, into CMS’s response to COVID-19 outbreaks in nursing homes and efforts to prevent future transmission of the virus. Rep. James Clyburn (D-SC), who chairs the committee, sent letters to CMS, as well as five of the largest for-profit nursing home companies, raising concerns with the Trump Administration’s COVID-19 response.
The Subcommittee continues to request that CMS provide details regarding how it enforced health and safety regulations at nursing homes as the outbreak worsened. Democrats on the Subcommittee have faulted the Trump Administration's overall response to coronavirus for the challenges seen in nursing homes, specifically for allowing these facilities to suffer without enough PPE and test kits.
Following their investigation into assisted living faciliites’ response to COVID-19, Sens. Elizabeth Warren (D-MA) and Ed Markey (D-MA) and Rep. Carolyn Maloney (D-NY) introduced legislation attempting to address the COVID-19 crisis in assisted living facilities. The Assisted Living Facility Coronavirus Reporting Act would:
Require states to report to the CDC, for each assisted living facility in the state, both historic and weekly COVID-19 data, broken down by demographic information;
Require assisted living facilities to notify federal, state, and local health officials, as well as residents and their loved ones, by the next day of the occurrence of confirmed COVID-19 cases in the facility;
Require HHS to apply all future COVID-19 reporting requirements for nursing homes to assisted living facilities, to the extent practicable; and
Require the Government Accountability Office (GAO) to issue a report, within two years, providing recommendations for improving data reporting by congregate-care facilities during the COVID-19 pandemic and future public health emergencies.
The Administration’s Response
On May 22, HHS announced plans to distribute $4.9 billion from the provider relief fund to skilled nursing facilities as nursing homes continue to call for more funding to test residents. Each nursing home received $50,000, plus a distribution of $2,500 per bed. Certified nursing homes with six or more certified beds were eligible. This funding was included in the Coronavirus Aid, Relief, and Economic Security (CARES) Act, which was signed into law on March 27.
With regard to testing, CMS Administrator Verma has repeatedly doubled-down on the claim that nursing homes have enough tests and touted CMS’s efforts to increase Medicare reimbursement for nursing homes that send COVID-19 testing samples to labs.
On June 19, CMS announced 25 members of an independent commission that will assess nursing homes’ response to COVID-19 and provide recommendations on immediate and future responses. The commission includes health officials from various states, including Texas and Ohio; doctors from various health systems nursing home lobby; advocates for nursing home residents; professors from various medical schools, including Harvard University and Johns Hopkins University; and directors of nursing homes.
Lastly, the Trump Administration directed the Federal Emergency Management Agency (FEMA) to distribute PPE to nursing homes. This assistance should be received by July 4 and comes in the form of “care packages” containing seven days’ worth of PPE. Advocates have labeled this distribution as wholly insufficient.
Response from the Campaign Trail
While the Trump campaign has not made any policy announcements or statements regarding efforts to respond to COVID-19 in nursing homes, Vice President Joe Biden’s campaign has released a comprehensive plan for combatting the coronavirus outbreak. The plan includes policies to protect nursing home residents and employees from infection. Specifically, the Biden plan would expand the Centers for Disease Control and Prevention (CDC) programs for random testing of populations in nursing homes to find and eliminate outbreaks. Additionally, it would provide resources to expand hiring for nursing homes in order to address new needs that have arisen due to the pandemic. Vice President Biden has consistently emphasized the importance of PPE for healthcare workers and has pledged to direct the government to supply nursing home facilities with resources needed to fight the virus.