Perhaps a year ago — allowing for the murkiness of remembering timelines before COVID-19 — I got an unusual recommendation from an executive at a senior housing and skilled nursing lender: Report on the history of companies that used to be major players in the skilled nursing space.
A news website that provides new content each business day is not typically a place for corporate history, but this executive argued that an examination of this past was, in fact, relevant to the daily news cycle. In fact, it was critical to understanding how today’s companies might end up faring in an era of major change for skilled nursing providers.
The toll of the COVID-19 pandemic in nursing homes proves this point in terms that are inescapable: almost 46,000 COVID-19 deaths reported from the care setting as of August 2, according to data gathered by the Centers for Medicare & Medicaid Services (CMS) that almost certainly represents an undercount.
And even though the first major outbreak of COVID-19 in the U.S. took place in a SNF in February, case counts in nursing homes in the U.S. are still climbing almost half a year later. In fact, according to one analysis from the nursing home trade group American Health Care Association (AHCA), U.S. nursing facilities reported 9,715 confirmed COVID-19 infections during the week ended July 26. The previous peak of infections had been 9,421 new weekly cases, recorded at the end of May.
Numerous reports have surfaced over the course of the pandemic on issues ranging from shortages of personal protective equipment, testing supplies, and timely and adequate testing. But the challenges brought on by the pandemic are indicative of long-simmering problems in the nursing home sector at large, as one certified nursing assistant testified at a hearing of the House of Representatives Oversight Committee in June.
“The only thing COVID did was rip the doors open,” Chris Brown, a CNA working in Chicago, told the committee. “It blasted the doors open of a system that was already failing.”
Without question, there needs to be a reckoning for those entities that failed through their own negligence to protect their residents and staff during the pandemic. But without an examination of conscience societally — examining what was and was not done over the history of caring for the sick, the elderly, and the vulnerable — it’s unlikely that we’re going to learn anything from the pandemic.
A society that valued and respected the lives of those who need assistance and support in their old age would not be using an arcane system of supplemental payments to shore up Medicaid rates that cover the care for the majority of those people. Several states in the U.S. have been using such a system for years, with the result that when the rules could be changed, billions of dollars at least intended for the care of seniors hang in the balance, with unknown consequences if they disappear.
A society that valued and respected the lives of those who need assistance and support in their old age would place a significant value on the certified nursing assistants who care directly for the elderly, rather than paying them wages significantly lower than those of many cashiers and fast-food workers.
And a society that valued and respected the lives of those who need assistance and support in their old age might not put so much of this care in the hands of corporations, even though — like many other parts of the overall health care ecosystem— the solid majority of nursing home operators are for-profit entities.
Companies must make money to survive in the U.S. economy, and health care companies are no different. When business decisions could end up having consequences for the lives of people and families, the factors weighed have to go beyond profit and loss, but nothing about the U.S. health care landscape makes this easy for companies to do.
How did the U.S. find itself in this situation? One article that took a stab at this question was published in The Nation, with the eye-catching title “It’s Time to Abolish Nursing Homes.” It argues that the U.S. has made nursing homes an inevitable part of aging when it should be focusing on helping people stay home instead, tracing the history of legislation to care for seniors and and the history of institutional care in the U.S. to make its case.
It’s not an argument I agree with entirely: Some people will need round-the-clock care that can’t be provided at home, and many others who will need assistance as they age don’t have a home to stay in in the first place. But the article makes a serious effort to try to understand how the U.S. has reached a point where nursing home residents account for a staggeringly high proportion of U.S. COVID-19 deaths, despite comprising roughly 1 million of the U.S. population.
The government and the nursing home profession have to be willing to do the same — as does American society as a whole. And for operators, their own history might be a good place to start; governments have to be willing to do some digging as well, beyond reports confined to the COVID-19 response.
State and federal governments have both power and institutional inertia. But their decisions don’t emerge in a vacuum, and without a collective look at where we came from on this issue as a civilization, it’s going to be impossible to understand how to go forward in a way that doesn’t repeat — or worse, exacerbate — the mistakes made in the first several months of the pandemic.