The headlines are eye-opening: On Friday, the Kaiser Family Foundation reported that, as of as of April 23, there were more than 10,000 reported deaths from COVID-19 in long-term care facilities—in just the 23 states that publicly report this information. That may be shocking. But it should not be surprising.
COVID-19 has exposed and amplified our profoundly flawed system of caring for older adults and younger people with disabilities. We now have an historic opportunity to fundamentally rethink how we care for those frail seniors. And to provide the financial resources needed to make it work.
As a nation, we have been providing second-class personal care to frail older adults for decades. Not just in care facilities, but also in their own homes. Don’t pretend this is just a nursing home problem.
Getting what you pay for
How did this happen? Because we are unwilling to commit resources to their care, the supports and services older adults receive are inadequate—or worse. As Harvard professor David Grabowksi says simply, “we get what we pay for.”
The US spends about $800 billion annually on medical care for older adults—most on those with chronic disease and functional impairment. Medicaid spends a seventh as much–about $125 billion–on long-term supports and services.
Traditional Medicare does not pay for long-term care at all, except under rare circumstances. Medicare Advantage managed care is just beginning to provide modest supportive services.
Medicaid, funded by both the states and the federal government, will pay for long term care services, but only for those who are impoverished and very frail. And even though most older adults prefer to age at home, the default care setting for Medicaid remains nursing homes—the only place where the program will pay for room and board.
A flawed payment model
Nursing home-based long term care was created by poor policy decisions decades ago survives thanks to today’s flawed and antiquated payment system. Now, nearly all the long-stay residents of nursing homes are on Medicaid, even though few need skilled nursing care. And they are the very people who are most likely to have the pre-existing conditions that put them at highest risk of death from COVID-19.
Not every older adult can live in their own home. Absent a family caregiver, many may need (or even prefer) some group setting. It does not need to be a nursing home. But that is the only congregant housing Medicaid will pay for.
And in many states, Medicaid’s nursing home payment rates are lower than the cost of care. Facilities try to make up the difference by selling residents ancillary services such as medications. Still, many Medicaid residents must share rooms with strangers —often living in double or even quad rooms. Facilities are understaffed, especially on nights and weekends. And as we have learned, basic safety standards, such as infection control, often are unmet.
Ignoring infectious diseases
For years, residents of nursing facilities have endured outbreaks of other infectious diseases such as the norovirus (an especially nasty intestinal condition) and even the seasonal flu. One study found that 80 percent of non-foodborne norovirus cases occurred in long-term care facilities.
But we ignored the problem, or, worse, accepted it. Yet, we are surprised that these facilities became Petri dishes for COVID-19.
State Medicaid programs do provide home care benefits. But they are insufficient to support the need. The result: Families receive too few hours of supportive care, care workers are paid less than a living wage, and states often mask their limited home care benefits behind waiting lists that can last as long as 2 or 3 years.
Want to know about our national priorities? Think about how we pay the care workers who are the bedrock of the paid care system. Compare the median $11.57 hourly wage of a home care aide or the $13.23 wage of a facility-based certified nursing assistant with the $16.98 wage of veterinary technicians. The economic message: Our society values those who care for our cats far more than it values those who care for our mothers.
We have created a system that relies almost entirely on family members, who pay an enormous physical, financial, and emotional price to care for their loved ones. Underpaid direct care workers do nearly everything else, either in homes or facilities. And now we are asking them to do so under life-threatening conditions– with limited and slow testing and shortages of personal protective equipment.
Reform often is impossible because those who benefit from the status quo fight to preserve their position and their revenue. But this time, what is there to protect? In the time of COVID-19, our long-term care system is utterly failing both providers and older adults.
Operators of long-term care facilities could throw their energies behind short-term financial bailouts and protection from lawsuits. Or they could work with consumer advocates for real reform.
The other day, a paramedic who finished a shift testing nursing home residents for COVID-19 tweeted this: “I only hope that the government & the public remembers how much our society has failed our elders. They should not be living in fear, isolated and alone in their final days. They deserve better than this. Please remember after COVID-19.”