Ed note: Please see the following post about the need for regulations in this growing, yet underfunded and understaffed industry charged with taking care of an elderly vulnerable population. We must be informed and strong advocates for good care.
By Norma B. Coe and Rachel M. Werner in the NYT
Dr. Coe is the director of research and Dr. Werner is the executive director at the Leonard Davis Institute of Health Economics at the University of Pennsylvania.
For anyone who lives in a nursing home, the adequacy of the nursing staff is a life-or-death issue. That’s why the Biden administration issued federal rules last year setting minimum standards for staffing. By our estimate, they will save 13,000 lives a year. But those rules are now under attack.
The Trump White House should defend them, not reverse or weaken them as part of its larger effort to roll back regulations across government.
The rules, which were finalized last April, represent some of the most significant reforms in nursing home care in decades. They will also cost most nursing facilities more to operate by increasing staffing, and that is why the rules are now in grave danger. But it will be money well spent on the industry’s core mission: caring for residents.
President Trump’s choice to head the Department of Health and Human Services, Robert F. Kennedy Jr., told lawmakers at a confirmation hearing last week that although the rules “were well intentioned,” they would be a “disaster,” especially for nursing homes in rural areas. Twenty Republican state attorneys general have gone to federal court to quash the rules. So have nursing home industry groups.
This amounts to an assault on some of our most vulnerable Americans, the roughly 1.3 million people who live in nursing homes, where understaffing and turnover are major problems. The rules, which are being phased in over the next several years, require a registered nurse to be on site 24 hours a day, seven days a week, and mandate a minimum of 3.48 hours of nursing care per resident per day, mostly from nursing aides.
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That may not sound like a lot, but most nursing homes in the United States don’t meet those basic minimums. Staffing levels at 83 percent of nursing homes fell below the new requirements in the first half of 2023, according to our analysis.
As researchers who have studied nursing homes for decades, we know how crucial nursing home staff members are — and why efforts to roll back the new minimum staffing rules pose such a threat to the residents and their families who rely on these staffers.
This will be especially true in coming years. The fastest growing age group in the United States already is people age 65 and older. Roughly one in six Americans fall into that age group, representing 17 percent of the population. That percentage is expected to rise to 22 percent by 2040.
If we were to provide advice on choosing a facility for a loved one, we’d cite the number of nurses and their aides as one of the most important factors. In homes with more nurses and aides, residents experience fewer bedsores and urinary tract infections. They stay more active and live longer. But U.S. nursing homes suffer from significant staffing shortages.
What impact will the new regulations have? We reviewed estimates of the relationship between total nurse staffing hours and mortality from published research. What we found surprised us: Achieving the minimum staffing levels would save the lives of about 13,000 people per year in U.S. nursing homes, about the same number killed in drunken driving accidents. And that doesn’t include the infections and other severe medical issues that would be prevented.
It’s true that hiring and retaining staff members in nursing homes is challenging, particularly since the pandemic. But nursing homes outside rural areas have until 2026 to meet the new standards, with rural facilities getting even more time. Facilities are eligible for exemptions if they cannot reasonably meet the standards, and the federal government is providing $75 million in programs such as scholarships and tuition reimbursement to train the next generation of caregivers.
The Biden administration estimated the new rules would cost about $4.3 billion a year. One major industry group says that number is $6.5 billion a year.
The industry is opaque about how nursing homes spend their funds. While reported profit margins are thin, facilities regularly funnel their revenue into related firms that do business at inflated prices, effectively hiding profits. A recent analysis by the National Bureau of Economic Research found that over two-thirds of profits are hidden this way. Artificially low profits shouldn’t be used as justification to eliminate important standards, putting profits over the residents themselves. But that seems to be what the industry wants.
Interestingly, a 2023 analysis of the rules’ impact by KFF, formerly the Kaiser Family Foundation, found that 90 percent of for-profit nursing facilities would need to hire more registered nurses or nurse aides compared with 60 percent of government and nonprofit facilities to comply with the proposed staffing minimums.
Many nursing homes may need to make only minimal changes to comply. While just about 20 percent of nursing homes now meet these standards, our analysis found that an additional 14 percent are out of compliance by only a small amount, or for only a few months of the year. The rules also include hardship exemptions for facilities that truly can’t meet the requirements, minimizing the burden on the most vulnerable institutions.
The truth is, nursing homes can meet these standards. The for-profit nursing home industry diverts hundreds of millions in profits to executives and shareholders — money that could be redirected toward hiring more nurses. California, where increasing minimum staffing requirements have existed for over two decades, has seen a net increase in the number of nursing homes, while at the same time there has been lower mortality, better nurse retention and higher quality of care.
The federal government’s minimum staffing requirements offer an opportunity to provide better care for older Americans and prolong their lives. We shouldn’t let that slip away.