Is Nursing Home Reform Part of Healthcare Reform?

2022.07.19 Nurse_in_geriatry

The short answer is, Yes.

Let’s drill down in more detail, and look at the National Academies’ new report on The National Imperative to Improve Nursing Home Quality.

Some First Questions

We can, first, ask the same questions about nursing home care as about healthcare in general.

  • Is nursing home care a right or a privilege? Or is it simply a market commodity?
  • Or – spoiler alert, as this blog has argued about healthcare — is it better understood as part of the social contract?
  • If it’s a “contractual” duty of society, are there limits? And should benefits be universal, publicly progressively funded (like Social Security), or means-tested?
  • Or, if provided more as a marketable commodity, should society (government) regulate it on behalf of consumers?

To Begin, Some Facts

Here are some salient facts.

  • Fully 56 percent of Americans will enter a nursing home during his or her lifetime. The average stay is now 9 months, with ten percent of stays lasting 3 years.
  • Nursing home care is but one of a range of services termed long-term care. Long-term care, in turn, is based on the nursing model of care that does incorporate medical treatment but focuses more on optimizing functional abilities, quality of life, and social support. This long-term care model is a better fit for chronic debilitating diseases like dementia, Parkinsons and multiple sclerosis. It contrasts to the acute care and disease-oriented medical model. Some other less-intensive examples are post-hospital rehabilitation, drug-and-alcohol services (and in fact all mental health services), home nursing care, and adult day care.
  • Family caregivers are estimated to provide “informal” care valued at $522 billion annually. This fact highlights the blurred line between what is medically necessary (owed by society) and what is a family responsibility (a private matter). Note: Some models of care embrace this melding. For example, the Veterans Affairs Department will subsidize family caregivers who forgo jobs and will give them periodic respites. Or adult day care allows the elder to spend nights and weekends at home but days under paid supervision.
  • Nursing home care itself is expensive, amounting to $197 billion annually in 2020. The current sticker price for the median nursing home is $7,756 monthly.
  • Medicare pays for only a 20-day post-hospital nursing home stay (or in rare cases an additional limited 80-day benefit). Medicaid pays for most nursing home care, fully 62 percent of all nursing home funding. The remainder comes from out-of-pocket, and only 11 percent via long-term care insurance. Medicaid will pay for care only after patients have exhausted their own assets. This explains why many nursing home residents die as paupers.
  • The U.S. has 15,600 licensed nursing homes housing 1.3 million residents at any given moment.

So, What’s the Problem?

For starters, the pandemic.

COVID-19 disproportionately mowed down nursing home patients and (literally) decimated staff. Of the now one million-plus total American deaths from COVID-19, 154 thousand were among nursing home patients. Nursing home staff deaths have totaled 2,451. And of the surviving staff, 241,000 quit between February 2020 and March 2022, 15 percent of the total workforce.

Understaffing is now an after-shock of the pandemic earthquake. Research has shown that more staff hours – especially more R.N. hours – correlates with increased longevity, fewer hospitalizations, fewer bedsores. The Centers for Medicare/Medicaid Services (CMS) has recommended 2.75 hours as the minimum staff hours to prevent harm, 3 hours as the preferred minimum, and 4 hours (including 1 hour of licensed nurse care) as optimum.

Understaffing correlates with higher staff stress and increased instances of patient abuse and neglect (as reflected in quality survey violations).

So, understaffing is lethal. And it tramples on dignity and quality of life for our now-frail former teachers, shopkeepers, and other neighbors.

Is Profit Motive the Crux?

The new report from the National Academies of Science, Engineering and Medicine (NASEM), released in April 2022, cites evidence that residents in for-profit nursing homes fare worse than those in not-for-profit or government-owned facilities, and those in Wall-Street-investor-acquired facilities fare worst of all. This report calls out unscrupulous owners and operators, who “cook the books to increase profits,” including skirting staffing requirements and outsourcing services.


Here are the seven broad goals in NASEM’s new report.

First and foremost is a reaffirmation of our society’s commitment to dignity, quality of life, and equitable person-centered care for our frailest elders.

This, in turn will require increased transparency and accountability for finances, operations and ownership of nursing homes. And this must especially translate into a well-prepared, empowered and compensated workforce, with specific mention of health benefits, child care, sick leave, training and career advancement opportunities.

The other goals are:

  • A more rational and robust financing system
  • More effective and responsive system of inspections and corrective actions
  • Enhanced quality measurement methodologies
  • Adoption of information technology in all nursing homes.


Sounds like healthcare reform in one precious corner of our wider healthcare system!

Take Action

President Biden gave attention to nursing home reform in his State of the Union address in March. Now it’s our turn!

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Image Credit

Title:  Nurse in geriatry (A woman’s 78th birthday December 2005, Ardencraig Care Home, Glasgow).

By:  I Craig from Glasgow, Scotland, CC BY 2.0, via Wikimedia Commons


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