To understand who or what is to blame for the more than 100,000 deaths caused by the coronavirus among residents and staff of U.S. long-term care facilities between March and Thanksgiving, it’s useful to consider a devastating calamity that hit in 2005: Hurricane Katrina.
In the days, weeks and months after New Orleans was overwhelmed with flooding from the hurricane, critics pointed to the slow response from the federal government, decisions made by the city’s mayor and the state’s governor, a delay in engagement from the U.S. president, the greed and influence of private businesses, and even the stubbornness of the city’s residents as the causes for all the pain that had occurred. And many of the charges had some level of truth. But in time, two simple but profound causes were ultimately found to be the root of what happened: bad infrastructure decisions that dated back decades—in New Orleans’ case, a poorly maintained, inadequate levee system — and a storm of such magnitude that once 23 of the levees were breached, little could be done to prevent 80 percent of the city from going underwater.
Experts foresee a similar reckoning for what has been happening in America’s nursing homes during the COVID-19 pandemic. Yes, they say, fingers can and should be pointed at how elected officials, regulators, owners and others responded to the crisis. But the American nursing home industry exists as it does today because of federal laws and regulations that go back 85 years. The infrastructure these laws created, no matter how well intended, didn’t anticipate the future, nor could it foresee a health storm of this magnitude, speed and deadliness.
To fully understand the underlying causes of the nursing home debacle of the past nine months, AARP spoke with dozens of experts, from scientists and researchers to historians, doctors, nursing home staff and industry heads. The interviews revealed large and small mistakes made at every level, from the federal government to states, local health departments and individual nursing homes. Here’s what they told us.
- 1950s laws led to hospital-like settings for most nursing homes
- 1960s laws ultimately made nursing homes reliant on government funding
- Medicaid rules force many into nursing homes against their desires
“Look at it from the 30,000-foot level,” says Eric Carlson, an attorney at Justice in Aging, who testified before Congress in June on the impact of the virus on nursing homes. “If you are living in a world with potential for pandemic, which we are, it seems like bad practice to put 150 people in their 80s together in tight quarters, two to a room, sleeping 4 feet away from each other. That’s about the worst thing you can do.”
Yet that’s precisely what federal laws governing America’s more than 15,000 nursing homes have led us to. In fact, the law that created Social Security back in 1935 planted the seeds. In an attempt to keep older Americans out of public poorhouses, the Social Security Act prohibited payments to residents of public institutions; that helped launch the rise of private nursing homes.
The next law with a major influence on today’s nursing homes came in 1954. The Hill-Burton Act, which funded hospital construction, was expanded that year to provide loans and grants to build nursing homes that agreed to provide low-cost care. The law instituted the medical model of nursing homes, in which older adults are housed in institutions that resemble hospitals more than, say, a college dorm or apartment. It’s a model that carries on today.
But even more influential to the industry was the creation of Medicare and Medicaid in 1965. Medicare, the federal health insurance program for individuals 65-plus, was set up to pay for doctor and hospital visits as well as short-term stays in nursing homes. But Medicaid, which covers primarily the poor, and is funded by matching state and federal funds, became the payer for long-term care in nursing homes.
Before the launch of Medicare and Medicaid, few families struggled to pay for nursing home care, says Bruce Vladeck, an expert on nursing home policy who in the mid-1990s was the administrator of the federal agency that directed Medicaid and Medicare. Back then, nursing home care was relatively inexpensive, he says. And few people lived long enough to require it.
But as life expectancy grew dramatically in the last half of the 20th century, so did the cost of medical care and nursing homes. That created the financial hardship many middle-
class Americans face today. “The great takeoff in health care prices in this country didn’t start until the early ’60s,” Vladeck says.
The Medicaid entitlement, critics say, is most responsible for the nursing home industry we have today. Although multiple studies and surveys show that few older people would choose to live in nursing homes, such facilities have become the only viable option for those who can no longer live in their homes without paid help.
Under Medicaid law, states are required to pay for nursing home care for anyone who qualifies. States are not required to pay for the home- and community-based services that would help seniors stay in their homes. If a state wishes to provide these services, it can apply for a waiver from the federal government. Even if approved, many waivers have enrollment caps. And in some cases, waiting lists for those wanting Medicaid-covered home care are so long that people die waiting.
Making nursing homes the de facto choice for older Americans in need of care set the stage for the ravages of the pandemic, says Patricia McGinnis, executive director of California Advocates for Nursing Home Reform.
“Nursing homes are not good places for anyone except for short-term rehab,” McGinnis says. “I would hope this is a wake-up call that the system isn’t working.”
- Early pandemic decisions deprioritized nursing homes
- Months of limited testing let the virus go unchecked