At a roundtable discussion with HHS Secretary Xavier Becerra on March 30, which the Center for Medicare Advocacy attended as one of seven invitees, Mark Parkinson, President and CEO of the American Health Care Association, the trade association of for-profit facilities, said that the primary issue in President Biden’s nursing home reform agenda that the nursing home industry could not support was staffing standards. Provider complaints about staffing levels are premature. There are no new federal staffing levels. The Biden Administration is requiring a new study of staffing standards, whose findings and recommendations it will implement through notice and comment rulemaking.
Moreover, the President’s nursing home reform agenda calls for immediate efforts to assist in strengthening staffing – ensuring that aide training is affordable, supporting “state efforts to improve staffing and workforce sustainability” (by developing “a template to assist and encourage States requesting to tie Medicaid payments to clinical staff wages and benefits, including additional pay for experience and specialization”), and launching a “National Nursing Career Pathways Campaign” in collaboration with the Department of Labor, “to conduct a robust nationwide campaign to recruit, train, retain, and transition workers into long-term care careers, with pathways into health-care careers like registered and licensed nurses.” These activities will help ensure more trained and available staff are available across the country when a federal staffing standard is implemented.
Nevertheless, at the meeting with Secretary Becerra, Parkinson gave two reasons for opposing federal staffing standards: there is no one to hire and increased staffing is financially unsupportable. Neither reason withstands scrutiny for the following reasons:.
- These Positions Could be Filled
Although there are nearly 4.2 million registered nurses (RNs) and 950,000 licensed practical nurses/licensed vocational nurses in the United States, only 64.9% of currently employed RNs and 65.7% of currently employed LPNs/LVNs actually work in nursing full-time. Encouraging some of these nurses to return to the nursing profession could help ease the current crisis in staffing. Recent surges in nursing school enrollment as well as various federal and state loan forgiveness programs can also help increase the numbers of licensed nurses.
In addition, states are already undertaking successful efforts to increase the numbers of trained and available paraprofessional direct care workers. For example, on December 6, 2021, Minnesota Governor Tim Walz announced a state initiative “to recruit, train, and deploy at least 1,000 newly certified nursing assistants for Minnesota long-term care facilities experiencing staffing shortages by the end of January.” Funded with $3.4 million in federal relief money and $6.7 million in state money, the program covered the cost of tuition, books, uniforms, and certification exam fees for participants. The State exceeded its 1,000 aide goal. On March 29, 2022, Governor Walz announced that 1,278 people participated in the initiative and that the state is continuing the successful Next Generation Nursing Assistant initiative with a proposed budget of $13.3 million for 2024-2025.
Many states are increasing Medicaid payments to facilities, often with mandates to use some or all of the money to pay workers higher wages and benefits.
In a new report, State Policy Strategies for Strengthening the Direct Care Workforce, PHI describes 24 specific policy strategies, with state examples, to improve the quality of direct care jobs and to help stabilize the direct care workforce. PHI documents the many state actions that are already underway to improve staffing.
- There is Money In Current Reimbursement to Pay For Increased Staffing Levels Paying for better staffing levels does not necessarily mean additional funding is needed.
- Existing reimbursement could be used more effectively to pay for increased staffing. New York State nursing homes and their trade associations challenged a new state law requiring nursing facilities to use at least 70% of their revenues to provide care to residents (including at least 40% for resident-facing staff) and to limit profits to 5%. The lawsuit filed by more than one-third of New York’s nursing facilities alleged that if the law had been in effect in 2019, facilities would have had to remit $824 million to the state. In other words, by their own calculations, New York State nursing facilities spent $824 million (in 2019) on excess profits and spending not related to resident care, as those terms are defined by the state’s 2021-2022 budget law. With direct care ratios like New York’s law, states and the federal government could require facilities to spend designated proportions of their existing reimbursement on care for residents.
- Paying a living wage to workers (which addresses one of the major reasons staff leave their jobs in facilities, low wages and the lack of benefits) could pay for itself. LeadingAge, the trade association of not-for-profit providers, issued a report in 2020, calling for workers to be paid a living wage. Using economic simulation, the report found that raising wages of direct care workers would reduce staff shortages, reduce staff turnover, improve health care quality, improve worker productivity, improve the financial security of direct care workers, reduce workers’ reliance on needs-based public benefit programs, and improve state and local economies. While the report did not identify who would the bear the costs of wage increases for workers, it found that “The emerging literature suggests that cost savings flowing from improvements in care quality may, alone, be enough to pay for wage increases.” In other words, raising direct care workers’ wages could pay for itself, just by improving care for residents. No additional reimbursement would be required to pay a living wage to workers.
- Staffing more appropriately could avoid spending to reverse the high costs of poor care. Bad care is expensive and costs money. A 2011 report by the National Consumer Voice for Quality Long-Term Care, which updated a report that the advocacy organization issued 20 years earlier on the same topic, identified research-based findings on the high costs of paying for avoidable bad outcomes related to falls, pressure ulcers, urinary incontinence, malnutrition, dehydration, and avoidable hospitalizations.
A second example of the high cost of poor care was documented in proposed rules for the Requirements of Participation in 2015, where the Centers for Medicare & Medicaid Services (CMS) identified the high costs of infections in nursing homes:
“Healthcare-associated infections (HAIs) often result in considerable suffering for residents in LTC facilities as well as increased costs for the healthcare system. Although estimates vary widely, there are between 1.6 and 3.8 million HAIs in nursing homes every year. Annually, these infections result in an estimated 150,000 hospitalizations, 388,000 deaths, and between $673 million to $2 billion dollars in additional healthcare costs (Castle, et al. Nursing home deficiency citations for infection control, American Journal of Infection Control, May 2011; 39, 4).”
Nursing facilities have been understaffed for decades. Reversing policies that allowed insufficient staffing to be the norm in nursing homes will not happen easily or overnight. But there can be no doubt that the quality of care and quality of life for nursing home residents will not improve unless and until professional and paraprofessional staffing dramatically improves. It is way past time to address this issue. President Biden’s nursing home reform agenda sets us on the right path and deserves full support.
April 14, 2022 – T. Edelman
 White House, “FACT SHEET: Protecting Seniors by Improving Safety and Quality of Care in the Nation’s Nursing Homes” (Feb. 28, 2022), https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/28/fact-sheet-protecting-seniors-and-people-with-disabilities-by-improving-safety-and-quality-of-care-in-the-nations-nursing-homes/
 A four-volume study, released in 2001 by the Centers for Medicare & Medicaid Services, found that more than 90% of facilities did not have sufficient staff to prevent avoidable harm or to provide the services required by the Nursing Home Reform Law. CMS, Report to Congress: Appropriateness of Minimum Nurse Staffing Ratios (2001). Phase One report at https://phinational.org/wp-content/uploads/2017/07/Phase_I_VOL-_II-1.pdf; https://phinational.org/wp-content/uploads/2017/07/Phase_I_VOL_I-1.pdf
 American Association of Colleges of Nursing, “Student Enrollment Surged in U.S. Schools of Nursing in 2020 Despite Challenges Presented by the Pandemic” (Apr. 1, 2021), https://www.aacnnursing.org/News-Information/Press-Releases/View/ArticleId/24802/2020-survey-data-student-enrollment (2021) (reporting 5.6% increase in enrollment in nursing schools, with 251,145 studying for baccalaureate level nursing degrees)
 “Governor Walz Announces Plan to Train, Deploy 1,000 New Certified Nursing Assistants to Long-Term Care by January 31; Effort is a partnership between state, colleges, and long-term care providers” (News Release, Dec. 6, 2021), https://mn.gov/governor/news/#/detail/appId/1/id/512110
 “State of Minnesota Surpasses Goal of Recruiting 1,000 Certified Nursing Assistants; Walz-Flanagan Budget to Move Minnesota Forward proposes additional funding to continue the initiative” (News Release, Mar. 29, 2022), https://mn.gov/governor/news/#/detail/appId/1/id/523325
 Illinois passed legislation, HB0246, https://www.ilga.gov/legislation/102/HB/PDF/10200HB0246enr.pdf, that, among other changes, subsidizes annual wage hikes for certified nurse aides, Peter Hancock, “Illinois lawmakers OK bill to drive $700M into Medicaid-funded nursing homes to boost care,” Capitol News Illinois (Apr. 8, 2022), https://www.sj-r.com/story/news/state/2022/04/08/illinois-bill-would-drive-700-million-nursing-homes-advances/9510576002/; the Colorado Legislature raised the minimum wage for nursing home workers to $15, House Bill22-1333, http://leg.colorado.gov/sites/default/files/documents/2022A/bills/2022a_1333_rer.pdf; The Star Tribune reports that Minnesota legislators introduced a billion-dollar proposal to increase wages of long-term care workers. Briana Bierschbach, “Minnesota legislators aim to tackle ‘dire’ staffing shortages in long-term care,” Star Tribune (Apr. 9, 2022), https://www.startribune.com/minnesota-legislators-aim-to-tackle-dire-staffing-shortages-in-long-term-care/600163652/?refresh=true
 PHI, State Policy Strategies for Strengthening the Direct Care Workforce (2022), reached through a link at https://www.phinational.org/resource/state-policy-strategies-for-strengthening-the-direct-care-workforce/
 New York State Budget for State Fiscal Year 2021-22, §2828 (Residential health care facilities; minimum direct resident care spending), https://www.nysenate.gov/legislation/laws/PBH/2828
 Home for the Aged of the Little Sisters of the Poor v. Mary T. Bassett, No. 1:21-cv-01384 (BKS/CFH) (N.D.N.Y., filed Dec. 29, 2021), https://medicareadvocacy.org/wp-content/uploads/2022/01/Nursing-homes-NY-nh-case-21-cv-1384-BKS-CFH-complaint-U.S.-District-Court-NYND-2.pdf . The Center for Medicare Advocacy has written about this lawsuit in “How Do Nursing Homes Spend the Reimbursement They Receive for Care?” (CMA Report, Jan. 26, 2022), https://medicareadvocacy.org/how-nursing-homes-spend-public-money/ and “New York Nursing Homes Suing the State Received Federal Provider Relief Funds” (CMA Alert, Feb. 3, 2022), https://medicareadvocacy.org/new-york-nursing-homes-suing-the-state-received-federal-provider-relief-funds/
 See LTCCC, Direct Care Minimum Staffing Laws; A Critical Tool for Improving Care for Nursing Home Residents and Accountability for Taxpayer Funds (2022), https://nursinghome411.org/wp-content/uploads/2022/04/Policy-Brief-Direct-Care-Min.-Spending-Laws.pdf
 See National Association of Health Care Assistants, “Survey: CNAs Cite Low Wages, Burnout, Lack of Respect as Key Contributors to Staffing Crisis” (Mar. 4, 2022), https://www.nahcacna.org/cnas-cite-low-wages-burnout-lack-of-respect-as-key-contributors-to-staffing-crisis/
 LeadingAge, Making Care Work Pay: How a Living Wage Benefits Us All (Fall 2020), https://leadingage.org/sites/default/files/Making%20Care%20Work%20Pay%20Report.pdf
 Id. 5.
 A humorous take on the issue – how paying a livable wage to workers would set off a ripple of good outcomes – is a column by Eleanor Feldman Barbera, “If you give the staff a livable wage . . . ,” McKnight’s Long-Term Care News (Dec. 7, 2021), https://www.mcknights.com/blogs/the-world-according-to-dr-el/if-you-give-the-staff-a-livable-wage/, which ends with “And if the staff is stable, the care is improved, rehospitalizations are averted, leaks are caught before floods, and penalties are avoided, organizations will have the funds to pay a livable wage.”
 Lani G. Gallagher, Consumer Voice, The High Cost of Poor Care: The Financial Case for Prevention in American Nursing Homes (Apr. 2011), https://theconsumervoice.org/uploads/files/issues/The-High-Cost-of-Poor-Care.pdf
 80 Fed. Reg. 42167, 42215 (Jul. 16, 2015), https://www.govinfo.gov/content/pkg/FR-2015-07-16/pdf/2015-17207.pdf