COVID-19 Crisis Reveals Deep Cracks, Conflicting Priorities in Nation’s Nursing Home Infrastructure

Over the course of decades, lawmakers have built a jury-rigged structure to support the American post-acute and long-term care landscape.

At the base, Medicaid supports long-term care residents who can no longer live on their own without around-the-clock care.

Medicare dollars pay for higher-acuity care that seniors require after hospital stays — and prop up insufficient Medicaid reimbursements that can’t financially sustain a nursing home on their own.


The federal Centers for Medicare & Medicaid Services (CMS) provides the guy wires of regulation, which tangle with the parallel scaffolding of rules that state and local governments have built up alongside their counterparts in Washington and Baltimore.

To protect themselves from liability and ambitious plaintiffs’ attorneys, operators covered up the windows to their offices with complex webs of intertwined ownership and management companies that even veteran journalists have struggled to unravel.

While such legal maneuvering is common and generally accepted in any industry with a significant real estate component, the nature of the clients that nursing homes serve — and the occasional horrific stories of serious lapses in care — made the media and the public deeply suspicious of what exactly was going on behind the curtain.


The vast majority of stakeholders who have contributed to this unwieldy model for providing care to the most vulnerable Americans made their decisions with seniors’ best interests at heart — a few more Medicaid dollars here to fortify the foundation, a new Medicare payment model there to fill in the cracks and curb fraud, and everything will be just fine.

Frankly, in “normal” times with no pressing enemy or battle to fight, gradual change and patchwork upgrades were all that the realities of politics and regulatory agencies could allow.

Then the hurricane-force winds of the COVID-19 crisis blew the whole structure down.

No one paying attention to the news, and watching the rapidly climbing coronavirus death toll at our nation’s nursing homes and other long-term care facilities, can be blamed for being angry.

My own blood pressure spikes when I go through my inbox each morning, scrolling past story after story about shortages of protective equipment and temporary morgues in refrigerated trucks.

I think about my great-aunt Gloria, a surrogate grandmother who received top-notch care at a non-profit assisted living and skilled nursing campus in Vernon, Vt. for the last years of her life. I think about how the staff loved her as much as I did, and how her experience showed me that senior care isn’t where you go to die — it’s where you go to live the best life you can, for as long as your body allows.

I think about the peace I felt after her death in 2012 at the age of 87, knowing that she spent her twilight in comfort, surrounded by caring people who kept her safe.

Then I imagine how things could have been different if she’d been alive today. I think about her every time I see a heart-wrenching story of families who must accept that, because of infection-control precautions, they were unable to be with their loved ones in their final moments. I put myself in their shoes, and I feel the anger and the grief and the frustration.

But I want to make sure that compassionate, comprehensive post-acute and long-term care options exist for future generations of grandmas and aunts and brothers and uncles. As we enter this next phase of the COVID-19 crisis, it’s important to direct that anger and grief and frustration at the right targets.

The federal government has taken some positive steps — restricting visits and focusing on infection-control inspections early in the process chief among them. While the industry itself has been out in front of CMS in many aspects, especially around calls for greater transparency about the number of reported cases, these steps reflect some understanding of how serious the situation would get, even before “social distancing” became a nationwide edict.

But the administration’s inability to coordinate the distribution of personal protective equipment (PPE) and COVID-19 testing kits represents a profound failure. In the United States, nurses should never have to use garbage bags and ponchos to protect themselves and their patients. In the United States, everyone should be able to receive testing during a pandemic, but CMS and states should have pushed nursing homes to the front of the line at the very first signs of danger.

CMS, the Department of Health and Human Services (HHS), and other federal agencies also must coordinate better with states. As someone who covers the industry every day, it’s been both fascinating and troubling to watch as the feds and states develop their parallel COVID-19 responses in real time — an effect perhaps best illustrated by the curious case of Massachusetts and cohorting.

Leaders in the Bay State were among the first to roll out an ambitious plan that would see nursing home operators volunteer certain buildings for COVID-19 cases, emptying them of residents and then converting them to coronavirus specialty centers.

CMS liked the idea so much that on April 2, administrator Seema Verma cited the Massachusetts model when announcing sweeping guidance that directed operators nationwide to create dedicated COVID-19 units and buildings of their own. But less than two weeks later, Massachusetts was forced to heavily modify that plan after long-awaited testing finally revealed more positive cases than officials anticipated.

Clearly, we are in unprecedented times, and well-meaning officials are going to make mistakes as they work to fight an unseen enemy. It’s just one example, but it reveals the deep tensions that exist between state and federal oversight of nursing homes, both from a regulatory and payment standpoint.

Operators must rely on the perfect combination of federal Medicare dollars and state-level Medicaid funding to survive. The two care models that those funds support couldn’t be more different, but persistent Medicaid shortfalls have made providing both short- and long-term care a necessity.

Without the Medicare money, a building simply can’t support itself or its residents on Medicaid alone — but as COVID-19 has revealed, bringing post-acute residents into a setting with even more vulnerable long-term care patients can be a recipe for disaster.

Once the danger passes, lawmakers at all levels need to deeply question the ways that federal and state rules around nursing homes overlap and diverge. Big-picture thinkers have long predicted the development of a site-neutral model, but it’s time to seriously consider a single federal payer source for all types of long-term and post-acute care. A split Medicare-Medicaid model, born largely by accident and sustained by inertia, falls apart in a crisis.

I understand that much of this is Monday-morning quarterbacking; leaders in the post-acute and long-term care space should prepare for a lot of that in the months and years to come.

When the coronavirus crisis abates — and operators and caregivers are no longer pleading for access to PPE and testing — my personal hope is that providers, lawmakers, and investors take seriously the opportunity to reflect on the failures baked into the system.

Maybe it’s finally time to prioritize across-the-board increases in wages for the people who have spent this crisis putting themselves and their families at risk, even if it’s at the expense at profit margins — temporary hazard pay and one-time stipends aren’t enough to fairly compensate these essential workers.

Maybe it’s finally time to embrace wholesale changes to payment models, instead of perceiving each tweak and update as an attack on the heart of the industry.

Maybe it’s finally time to tear down the wall of suspicion and derision that leaders on both sides have built up between the public and nursing home operators.

It’s natural for people who have devoted their lives to senior care to feel defensive when the media and resident advocates highlight the horrors of COVID-19.

I’ve met so many people throughout my time covering this industry who love the residents in their care as much as the team at the Vernon Homes loved my great-aunt. They’ll continue to provide that care, walking into the fire while the rest of us stay home, because that’s the work they feel called to perform.

But I hope, deep down, everyone who works in this space uses this crisis as an opportunity to reflect on their role in the landscape — and how they can work to rebuild the structure on a sturdier foundation.

I know I have.