The COVID Nursing Home Crisis Was 50 Years in the Making

Medicaid's funding structure ensures that profits are slim, so employees are overworked and sanitation problems and PPE shortages are common.

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As the coronavirus pandemic spread throughout the world this year, we quickly learned that the elderly, and particularly those with pre-existing conditions, are especially at risk of severe complications and death from COVID-19. It’s no wonder that those living in long-term care settings are perhaps the most vulnerable group in society.

Our research at the Foundation for Research on Equal Opportunity shows staggering numbers. There are 5.1 million elderly and disabled individuals who live in long-term care facilities, including nursing homes and assisted living facilities. These individuals represent only 1.6% of the population, but as of May 22, they account for 43% of all COVID-19 deaths in the U.S. And this is likely an undercount; excluding New York state (where COVID-19 nursing home fatality figures do not include those residents who die in the hospital), the average across all remaining states is 53 percent. Based on this metric, those hardest hit include Pennsylvania (69 percent), Ohio (70 percent), New Hampshire (70 percent), Rhode Island (77 percent), and Minnesota (81 percent).

We can also analyze fatality data in long-term care facilities by looking at the number of residents who have died as a share of the total population in those facilities. The fatality rates in the northeast are particularly grim. Coronavirus deaths per 10,000 residents in Massachusetts and Connecticut stand at 703 and 827, respectively. And at 954 fatalities per 10,000 residents, nearly 10 percent of all long-term care residents in New Jersey have died from COVID-19.

The U.S. is not an outlier for nursing home-related deaths due to COVID-19. Researchers at the International Long-term Care Policy Network found that of all fatalities in Australia, Belgium, Canada, Denmark, France, Germany, Hong Kong, Hungary, Ireland, Israel, Norway, Portugal, Singapore, and Sweden, half were nursing home residents.

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  1. Avatar photo
    Idontdocute

    The article states that Louisiana has barred covid-19 patients from being sent to a nursing home, unlike New York, but it doesn’t state what Louisiana did with them. After a search, I think the patients were sent to tier 2 / skilled nursing units which would move them in with surgical recoveries, injuries such as fractures, and stroke recoveries. The situation could raise so many concerns but we are in a season of a mountain of concerns with little data for guidance. We could throw our money and effort after any untried solution and fail because all of our solutions for this virus are untried.

    For example, could the spread in nursing homes be more related to fecal transfer than respiratory transfer? We can find virus RNA in fecal which could presume it is a route for transfer with live virus. We don’t know, it seems. It could help explain how it spreads in facilities that have a large number of incontinent residents. Have we stepped up containing this possible route with equipment, special handling of trash and linens, etc. I don’t think so.

    This is a crisis that has just started. We aren’t even sure if this is a respiratory disease or a clotting disease and yet the simplest of effective protections, hand washing, masking, and distance is beyond our ability. A three year old child could handle these three with simple instructions, but not our adults. We have a long way to go made harder, not by our overwhelmed health care system that cannot create staff, facilities, or solutions by wishing but by immature, self centered, entitled adults that cannot find enough internal value to be able to demonstrate simple external concern or courtesy.

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    Jessica Hughes

    Thanks for pointing out some of the systemic flaws that explain how we got where we are. I'm all about aligning incentives with desired outcomes, but I would like to know more about what the author means by this statement: "We could start by offering stronger support to family caregivers, who even today provide more long-term care than the entire corporate long-term care industry." I hope that isn't code for unpaid family care, most often by women, who are often torn between the competing demands of caring for their own children, their careers, and now their elderly parents. Of course family comes first but as the percentage of elderly in the US only increases, we need to find ways to make in-home care services, assisted living, and other community-based systems work in a way that doesn't become an even heavier burden on our working-age population, particularly women.

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      Mudskipper

      That was my thought exactly when I read that sentence. I'd add that unpaid care for family members is one of the reasons that many women end up being poor in old age.

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      1. P Satter

        Yes. 24 hour a day, 7 day a week unrelenting care is difficult for one person to provide, even for (one who starts out as) a very healthy retired spouse. And many seniors don't want to live with a child and have all aspects of care taken care of by another family member (and yes, it will be a female) who also has a job and/or young children. Nor do they wish to be parented by their own child, an uncomfortable dynamic not often considered.
        Assisted living, in particular, can be a very positive and much more cost-effective model (often one-third to half the cost) as compared to a nursing home. You are only paying for the care you are individually determined to need, independence is encouraged in your own apartment, and the model promotes greater social interaction.

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  3. Susan Kristof

    Good article. I have said since the beginning that: Low paid employees + no visitation policies + an easily attributed cause of death (possible COVID-19) could lead to neglect or worse in our LTC facilities. I saw it with my mother 6 years ago. If I had not been there to witness her mistreatment and literally drag her out of there in the middle of the night, her final days would have been agonizing. And this was in a highly rated home. The statistics are no surprise.

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    Visibly

    It is so difficult to find the right way forward for senior citizens. In Norway, we fail in this regard. Our national health services try to keep sick and often terminal people at home as long as possible. So, they can have nurses visiting 4 times a day. But they still fail in daily care. My father had dementia; he was first accepted for continued care after being violent against staff and other patients during a short term stay. He was accepted by a geritopsycological unit, with only 7-8 patients, and 3-4 staff members at any time. They were phenomenal, but unfortunately not available for others in society.
    My brilliant mother who had survived multiple scares with death over the last 30 y, including 3 different type of cancers (I start crying now), she was 100% clear until the last few months of her life. One of the most difficult things was to explain to her that we needed help to look after her. My last meeting with my mother was one of the very few times she cried, saying how difficult it was to die. She died in hospital just 4 days later, when I was away. She was lucky that she had medical doctors, in particular my brother, who looked after her at all times.

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    Kevin Johnson

    Really useful. Thanks.

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    Karen Grubaugh

    Well done!

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  7. William Lowery

    What an excellent article. Thanks for writing this. Another thing to keep in mind: seniors often divest their assets to be eligible for medicare. It's a perverse incentive that further reduces self-sufficiency and independence, making them all the more vulnerable. An "entitlement" system that compensated for at-home care and that was indexed to assets might do more to encourage less reliance on long-term nursing care (another win-win).

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    1. Clisby Williams

      I think you mean to be eligible for Medicaid?

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      1. William Lowery

        Doh! Yes. No edit feature, unfortunately...

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