- Improve Medicare for All Beneficiaries
- With Next COVID Relief Bill Stalled, President Trump Issues Directives of Questionable Authority and Threatens Social Security and Medicare
- Inspector General Finds More Than Half of All Nursing Facilities Failed to Meet Professional Nurse Staffing Standards in 2018
- Studies Find Higher Nurse Staffing Levels in Nursing Facilities Are Correlated With Better Containment Of Covid-19
- Nursing Facilities Owned By Private Equity Firms Have Higher Rates of Covid Infections than Other Facilities
- Center Attorneys Participate in Oral Health Gathering
Medicare is extremely popular, but it needs attention to ensure all beneficiaries receive comprehensive coverage and equitable treatment. The Medicare program that Americans know and cherish has been allowed to wither. Traditional Medicare, preferred by most beneficiaries, has not been improved in years, yet private Medicare Advantage plans have been repeatedly bolstered. It’s time to build a better Medicare for all those who rely on it now, and will in the future.
- Mandate parity between traditional Medicare and Medicare Advantage – in coverage and allocated resources
- Add an annual out-of-pocket cap to traditional Medicare
- Reduce drug prices by negotiating on behalf of all 62+ million Medicare beneficiaries
- Use the savings gained from negotiating drug prices to improve Medicare (as in HR 3, Elijah E. Cummings Lower Drug Costs Now Act, passed by the House on 12/12/2019)
- Increase traditional Medicare coverage, including for oral health, vision, and audiology services
- Improve access to Medigap plans so people with pre-existing conditions are not locked out
- Add an out-of-pocket cap on Part D expenses and strengthen low-income assistance
Improve and support Medicare for all beneficiaries.
Don’t accept anything less than the improvements included in HR 3.
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At the time of this writing, an impasse continues regarding the next COVID-19 relief bill. In May, the House of Representatives passed the HEROES Act, a $3.4 trillion COVID relief package; in July the Senate GOP introduced the HEALS Act, a $1 trillion relief package. There are significant differences between these proposals that negotiators have been unable to resolve.
On August 8, President Trump issued several executive measures aimed at addressing aspects of the COVID-19 crisis, ostensibly in response to the impasse.
Overview of Executive Measures
On August 8, 2020 President Trump issued four documents – one executive order and three memoranda – aimed at unemployment aid, eviction protection, student loan relief, and deferral of payroll tax payments.
Both the legality and the efficacy of these actions were immediately questioned. The New York Times characterized these executive actions as “a legally dubious set of edicts whose impact was unclear”. As summarized by the Washington Post, the President “attempted to bypass Congress and make dramatic changes to tax and spending policy, signing executive actions that challenge the boundaries of power that separate the White House and Capitol Hill.” Further, the “measures would attempt to wrest away some of Congress’s most fundamental, constitutionally mandated powers — tax and spending policy.”
If carried out, the Post notes, such actions “would provide only limited relief” and some of the President’s “new actions appear to be only instructions to his Cabinet secretaries and department heads to look for ways to address certain problems. Others involve more questionable actions such as the suspension of tax payments and transfers of money Congress has appropriated for another use.”
Payroll Tax Deferral
Of the actions taken by the President, the Center is particularly concerned about repercussions for Medicare and Social Security from deferring payroll taxes. (Directives concerning the payroll tax were included in a document entitled Memorandum on Deferring Payroll Tax Obligations in Light of the Ongoing COVID-19 Disaster, August 8, 2020.) This document attempts to defer payroll tax payments (retroactively to August 1) through December, for individuals earning less than $100,000. The memorandum also directs the Treasury Secretary to “explore avenues, including legislation, to eliminate the obligation to pay the taxes deferred.” As noted by the Post, “[t]he impact of this measure could depend on whether companies decide to comply, as they could be responsible for withdrawing large amounts of money from their employees’ paychecks in a few months when the taxes are due.”
According to the Center on Budget and Policy Priorities, this deferral will not “significantly aid the economy” in part because “[e]mployers and workers will still owe the taxes and have to pay them at a later date, so they will be reluctant to spend the money now and, in turn, help stimulate the economy. Moreover, employer decisions on hiring and investment will be driven by the demand for the goods and services they produce, not whether they owe these taxes now or later.”
Importantly, however, payroll taxes fund key components of Social Security and Medicare Part A. According to an analysis by Inside Health Policy (“Dems Concerned Trump’s Long-Term Tax Plans Could Harm Medicare” by Michelle M. Stein, August 9, 2020) the “payroll tax holiday doesn’t appear to affect the Medicare portion of those taxes” based on the federal code sections referenced in the directive, although “one analyst said it’s a small step to go from not collecting the taxes that fund Social Security to not collecting the Medicare taxes and some lawmakers worry Trump is setting the stage to defund taxes supporting Medicare.”
Longer-Term Threat to Medicare and Social Security
As the President signed these executive actions, he vowed that, if re-elected, he would seek to extend the payroll tax deferral and pursue a permanent cut to payroll taxes, an effort that, according to the Post, “some experts see as a major headache for the future of the country’s entitlement programs.” The New York Times notes that if the President “tried to make a payroll tax cut permanent, it would have a drastic effect on the funding of Social Security, which he has previously vowed not to cut.” Further, the Post noted, in a separate article, that since the payroll tax funds Social Security and Medicare, “it’s unclear where those programs will get funding if the taxes are deferred.”
The Center for Medicare Advocacy urges Congress to quickly pass a comprehensive COVID relief bill in order to help the country and people in need carry on through the pandemic. The Center also opposes ill-advised efforts to deplete or cut-off funding to Social Security and Medicare, our country’s bedrock social insurance programs that will continue to be lifelines for people long after the pandemic subsides.
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Federal law requires that nursing facilities voluntarily choosing to receive reimbursement from Medicare, Medicaid, or both programs meet certain professional nurse staffing requirements: A registered nurse (RN) must be on-site eight consecutive hours per day and licensed nurses (RNs or licensed practical nurses, LPNs) must be on-site 24 hours per day. In an analysis of 2018 staffing data submitted by 12,862 nursing facilities to the Centers for Medicare & Medicaid Services (CMS) under the Payroll-Based Journal (PBJ) system, the HHS Office of Inspector General finds that more than half the facilities failed to meet professional nurse staffing standards:
- 943 facilities (7%) failed to meet these staffing standards for at least 30 days in 2018.
- These facilities did not have an RN present for at least eight hours for an average of 58 days.
- These facilities did not have licensed nurse services available for at least 24 hours for an average of 15 days.
- 900 facilities (7%) failed to meet these standards between 16 and 29 days in 2018.
- 5,127 facilities (40%) failed to meet these standards between one and 15 days in 2018.
- Most of the noncompliant staffing levels (65%) occurred on weekends.
As OIG recognizes, CMS has long “identified nurse staffing as a vital component of a nursing home’s ability to provide quality care.” New research conducted during the coronavirus pandemic confirms again the critical importance of RN staffing; 20 additional minutes of RN coverage in Connecticut nursing facilities was associated with 22% fewer confirmed cases of COVID-19 and 26% fewer COVID-19 deaths.
As the OIG reports the shortages of professional nurses in nursing homes in 2018, new public policies established in the future must ensure that all facilities have sufficient numbers of professional nurses as well as paraprofessional nurses (certified nurse assistants). Higher staffing standards are essential and these standards need to be effectively enforced.
 42 U.S.C. §§1395i-3(b)(4)(C)(i), 1396r(b)(4)(C)(i)(II), Medicare and Medicaid, respectively; 42 C.F.R. §483.35(b)(1).
 42 U.S.C. §§1395i-3(b)(4)(C)(i), 1396r(b)(4)(C)(i)(I), Medicare and Medicaid, respectively; 42 C.F.R. §483.35(a)(1)(i).
 OIG, Some Nursing Homes’ Reported Staffing Levels in 2018 Raise Concerns; Consumer Transparency Could Be Increased, OEI-04-18-00450, p.3 (Aug. 2020), https://oig.hhs.gov/oei/reports/OEI-04-18-00450.pdf.
 Id. 3, 4 (Exhibit 2).
 Id. 1, endnote 1, citing Kramer, A.M., and Fish, R., “The Relationship Between Nurse Staffing Levels and the Quality of Nursing Home Care,” in Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes: Phase II Final Report, Abt Associates, Inc., Winter 2001. This study, also known as the CMS Staffing Study, found a clear association between nurse staffing and nursing home quality of care. CMS, Nursing Home Compare Technical Users’ Guide—April 2019, https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/CertificationandComplianc/downloads/usersguide.pdf. Accessed on November 14, 2019.
 Yue Li, “COVID-19 infections and deaths among Connecticut nursing home residents: facility correlates,” Journal of American Geriatrics Society (2020) (in press).
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Four recent studies using different databases, criteria, dates, and states all confirm that nursing facilities that have more nurses are more successful in containing coronavirus cases and deaths among residents than facilities with lower nurse staffing levels.
Data from 4,254 nursing facilities provided by eight state health departments for the period January 1, 2020-June 3, 2020 indicate that facilities rated highly on nurse staffing levels, as reported on Nursing Home Compare, had fewer COVID-19 cases than facilities with lower nurse staffing ratings.
Examining CMS Nursing Home COVID-19 data, as of June 14, 2020, researchers find that while nurse staffing levels may not determine whether COVID-19 gets into a nursing facility, both higher nurse aide staffing and total nurse staffing “are associated with lower probability of a larger outbreak and fewer deaths.” Although the impact of staffing levels is “relatively small” and dwarfed by the impact of COVID-19 in the community, staffing levels are important in “implementing efforts to stem transmission, such as regular testing and cohorting of both residents and staff.”
A study of all 215 Connecticut nursing facilities with confirmed COVID-19 cases and deaths as of April 16, 2020 finds that every 20 minutes per resident day of increased staffing by registered nurses was associated with 22% fewer confirmed cases of COVID-19 and 26% fewer COVID-19 deaths.
Data from the California and Los Angeles Departments of Public Health, reflecting nursing facilities reporting COVID-19 infections between March 15 and May 4, 2020, show that “a higher proportion of nursing homes with COVID-19 residents had lower RN hprd [hours per resident per day] and lower total nursing hprd” as well as “lower CMS Medicare five-star total staffing and lower RN ratings.”
Kaiser Health News reported the importance of registered nurses in California’s nursing facilities. As of April 28, 2020, California facilities that had one or more residents with COVID-19 “had on average 25% fewer registered nurses per resident in the final three months of 2019.”
Avoiding COVID-19 entirely may, in some instances, be a matter of luck, but containing COVID-19 and reducing the number of COVID-19 deaths are related to increased nurse staffing levels.
 “Association of Nursing Home Ratings on Health Inspections, Quality of Care, and Nurse Staffing With COVID-19 Cases,” Journal of the American Medical Association (Research Letter) (published online Aug. 10, 2020), https://jamanetwork.com/journals/jama/fullarticle/2769437?guestAccessKey=258f9d19-b7c2-43e2-9218-55c23d3914bc&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jama&utm_content=olf&utm_term=081020. The researchers used state health department data, which they view as more reliable than the national COVID-19 data set. The states are California, Florida, Illinois, Maryland, Massachusetts, New Jersey, and Pennsylvania.
 Rebecca J. Gorgees, R. Tamara Konetzka, “Staffing Levels and COVID-19 Cases and Outbreaks in US Nursing Homes,” Journal of the American Geriatrics Society (published Aug. 8, 2020), https://onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.16787.
 Yue Li, H Temkin-Greener, S Gao, X. Cai, “COVID-19 infections and deaths among Connecticut nursing home residents: facility correlates,” Journal of American Geriatrics Society (2020), https://onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.16689.
 Charlene Harrington, L Ross, S Chapman, E Halifax, B Spurlock, D Bakerjian, “Nurse Staffing and Coronavirus Infections in California Nursing Homes,” Policy Politics & Nursing Practice, https://journals.sagepub.com/doi/10.1177/1527154420938707?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed.
 Jordan Rau and Anna Almendrala, “COVID-Plagued California Nursing Homes Often Had Problems In Past,” Kaiser Health News (May 4, 2020), https://khn.org/news/covid-plagued-california-nursing-homes-often-had-problems-in-past/.
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Recent analyses of private equity firms find that facilities taken over by private equity firms provide poorer care to residents and have lower nurse staffing levels, while admitting more residents and increasing their lengths of stay. As a consequence of these practices, it is not surprising that recent studies document that nursing facilities owned by private equity firms have higher rates of COVID-19 infections and deaths than facilities with other ownership patterns.
The Portopiccolo Group, as described in Barron’s, is a private equity firm started in 2016 that now operates 100 facilities under various names, such as Accordius, Pelican Health, and Orchid Cove. At least 10% of Portopiccolo-affiliated facilities have been cited with infection control deficiencies during targeted infection control surveys conducted since March 2020, more than three times the rate of nursing facilities nationwide.
Barron’s describes COVID-19 rates in several Portopiccolo facilities. Accordius acquired Citadel Salisbury, a North Carolina nursing facility with 160 beds, in 2020. The facility had the largest COVID-19 outbreak in the state – 168 COVID cases among residents and staff, including 18 deaths. Mills Nursing and Rehabilitation, a Kentucky nursing facility with 98 beds, has had 107 COVID-19 cases among residents and staff and 23 deaths.
Barron’s reports that among the 75 facilities listing Portopiccolo’s CEO as an owner in federal regulatory data, 43% have one star, the lowest rating, compared to 17% of facilities nationwide. Only three of the 75 facilities “exceed the national average total nurse staffing of 3.86 hours per resident day.”
An analysis of COVID-19 in New Jersey nursing facilities by the Americans for Financial Reform Education Fund finds that while facilities operated by private equity firms account for 15% of the state’s nursing facilities, they account for 20% of the coronavirus cases and deaths. 58.8% of residents in facilities owned by private equity firms contracted COVID-19, 24.5% higher than the statewide average.
Private equity facilities in New Jersey provide 20% fewer hours of nursing care per resident per day and are cited with more deficiencies than nonprofit and public facilities.
The Americans for Financial Reform Education Fund recommends that
- “Private equity be prohibited from owning health care facilities and assets like nursing homes.”
- “The federal government must require the disclosure of the ultimate corporate owners and operators of federally certified nursing homes.”
- “The federal government should impose strict staffing standards to protect workers and residents.”
Similar recommendations for better, more explicit staffing standards and for more effective enforcement have been made before. The COVID-19 pandemic has made these recommendations more important than ever.
 Atul Gupta, Sabrina T. Howell, Constantine Yannelis, and Abhinav Gupta, “Does Private Equity Investment in Healthcare Benefit Patients? Evidence from Nursing Homes?” (Feb. 2020) full report available through https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3537612; Eleanor Laise, “Private-equity takeover of nursing homes has reduced quality of care at critical moment, research suggests; for-profit ownership and private-equity backing of nursing homes, academic studies show, may weaken facilities’ staffing levels and compliance with federal standards,” MarketWatch (Mar. 14, 2020), https://www.marketwatch.com/story/coronavirus-pandemic-puts-private-equity-ownership-of-nursing-homes-under-microscope-2020-03-14?adobe_mc=MCMID%3D27544074148082056223030259368856516599%7CMCORGID%3DCB68E4BA55144CAA0A4C98A5%2540AdobeOrg%7CTS%3D1596726240; Americans for Financial Reform Education Fund, “The Deadly Combination of Private Equity and Nursing Homes During a Pandemic; New Jersey Case Study of Coronavirus at Private Equity Nursing Homes” (Aug. 2020), https://ourfinancialsecurity.org/wp-content/uploads/2020/08/AFREF-NJ-Private-Equity-Nursing-Homes-Covid.pdf.
 Eleanor Laise, “As the Pandemic Struck, a Private-Equity Firm Went on a Nursing –Home Buying Spree,” Barron’s (Aug. 6, 2020), https://www.barrons.com/articles/as-the-pandemic-struck-a-private-equity-firm-went-on-a-nursing-home-buying-spree-51596723053?mod=hp_DAY_Theme_1_1.
 Americans for Financial Reform Education Fund, “The Deadly Combination of Private Equity and Nursing Homes During a Pandemic; New Jersey Case Study of Coronavirus at Private Equity Nursing Homes” (Aug. 2020), https://ourfinancialsecurity.org/wp-content/uploads/2020/08/AFREF-NJ-Private-Equity-Nursing-Homes-Covid.pdf.
 Rohit Pradhan, Robert Weech-Maldonado, Jeffrey S. Harman, Mona Al-Amin, Kathryn Hyer, “Private Equity Ownership of Nursing Homes: Implications for Quality” (Jun./Jul. 2014), full text available at https://healthfinancejournal.com/index.php/johcf/article/view/12#:~:text=Despite%20wide%2Dspread%20public%20concern,remains%20limited%20%3B%20ergo%20this%20study.&text=Private%20equity%20nursing%20homes%20have,compared%20to%20the%20control%20group, discussed in CMA, “Nursing Facilities Owned by Private Equity Firms: Fewer Nurses, More Deficiencies” (CMA Alert, Aug. 20, 2014), https://medicareadvocacy.org/nursing-facilities-owned-by-private-equity-firms-fewer-nurses-more-deficiencies/.
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As part of the Center for Medicare Advocacy’s continued commitment to improving oral health for older adults and people with disabilities, and expanding Part B to include a comprehensive oral health benefit, Center attorneys participated in the virtual 2020 OPEN Academy this week. The Oral Health Progress & Equity Network (OPEN) is a national network of individuals and organizations that believe oral health is essential to overall health and wellbeing. The program’s purpose was to increase systems change capacity and skills, ground OPEN members in the current reality of 2020, and deepen our commitment to racial justice.
The Center continues to advocate for a comprehensive oral health benefit in Part B of Medicare. The Center also advocates for expanded coverage of oral health services that are integral to medical treatments. Recent research from the DentaQuest Partnership highlights the continuing need for adult oral health benefits in Medicare. The study shows the years living with disabilities due to oral health diseases in elderly adults and how a 5% increase in government spending is sufficient to cover these conditions. Recent polling also shows strong support among voters for a Medicare oral health benefit.
The Center for Medicare Advocacy thanks the DentaQuest Partnership for its support of this work and its ongoing commitment to adding a comprehensive oral health benefit to Medicare.
- More information on the Center’s oral health work: https://medicareadvocacy.org/medicare-oral-health-care-update/
- More information on OPEN: https://medicareadvocacy.org/new-oral-health-advocacy-collaborative-begins/
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