Why do we only care about long-term care in a crisis?
The COVID-19 pandemic highlights the tremendous sacrifice that Americans are willing to make to protect our most vulnerable people, including older adults and disabled individuals. Four-fifths of COVID deaths are among those over age 65, and the share of COVID deaths in long term care facilities is as high as 50 percent in some states.
To prevent the virus from taking a devastating toll on these vulnerable people, we have virtually shut down our economy and dramatically restricted our social interactions. Most Americans have willingly adopted unpleasant modifications to their daily lives. And to offset the economic losses that have resulted, we have spent $3 trillion on economic rescue funds, with more likely to come. In our view, this is money well spent.
Nevertheless, our response poses a puzzle. Why are we willing to turn our lives upside down, resulting in a need for trillions to support the shutdown of the economy, during this moment of crisis — but we are unwilling to dedicate even a small fraction of that amount to improve the quality of life and prevent deaths among vulnerable populations at other times?
Take nursing homes, the epicenter of the crisis, as an example. Although we are shocked and dismayed by the high COVID-19 death rates, we are not surprised given the low investment our nation makes in these facilities. Medicaid is the dominant payer of nursing home services and pays nursing homes less than their costs.
As a result, nursing homes cannot offer competitive wages and benefits to workers, such as certified nursing assistants (CNAs), leaving too many workers earning minimum wage and at poverty levels, and often without health insurance. Without livable salaries and lack of investment in professional development, annual turnover has been as high as 65 percent among CNAs.
In the current crisis, nursing home workers are frequently without adequate PPE and, therefore, at high risk of COVID-19 infection or even death. As a result, tens of thousands of positions are going unfilled. But the mystery is not why so many CNAs are not working. Instead the mystery is why so many continue working in these hazardous environments despite low pay and few benefits.
These are dedicated workers who are making enormous sacrifices for their jobs. We heartily endorse hazard pay for these essential workers — such as that proposed by the Heroes Fund — but that fix is temporary and the needs of this workforce are long-term. We need to reward these heroes even when we aren’t amid a pandemic.
Suppose we were to raise the pay of all of the nation’s CNAs by $10,000/year, or $5/hour for a full-time worker. This would have a total cost of $20 billion per year— which is less than one percent of the amount we have spent in six weeks to fight COVID. And the benefits will be enormous. Studies suggest that nursing homes with higher-paid CNAs have more staff, lower turnover, and better quality.
To avoid overburdening state Medicaid programs, this extra pay should be fully financed by the federal government with instructions for pass through directly to worker pay. We could also fold in other benefits that compensate CNAs — ranging from better health coverage to paid sick leave to train programs that allow them to move up the career ladder to higher-paying jobs as nurses — at a comparatively low cost.
Of course, seniors live in the community as well. We often claim to want to support older adults of limited means in community settings, rather than going into institutions. Still, we only can offer slots to 25 percent to 33 percent of people qualifying for subsidized housing. Affordable housing, even for the poorest older people, is not an entitlement. We could triple the resources aimed at subsidized housing to accommodate low-income older adults in the community at the cost of only $2.7 billion annually.
Dedicated family caregivers opt to share their homes with older family members with cognitive impairments and other disabilities. To sustain these arrangements and preserve their ability to work and support the household, these caregivers must have adequate support services such as adult day programs.
These programs offer mental health, social work, therapeutic (occupational, physical and speech), dietary/nutritional and skilled nursing services. They serve a very needy population, with 58 percent being non-white or Latinx and a sick population, as 31 percent have some form of dementia, 31 percent have diabetes and 27 percent heart disease.
Yet such programs are persistently under-funded and are at risk of vanishing entirely under the threat of COVID. Ensuring that these important sources of community treated remain available involves relatively modest outlays; we could double funding of this valuable program for only $7.3 billion per year.
COVID, fortunately, will eventually pass. But the costs of addressing the long-run deficit in care for our nation’s seniors are a small fraction of what we are currently spending to fight COVID. The challenging working conditions in our nursing homes and the lack of community housing and adult day programs for low-income older adults have impacted the care of older adults for decades and potentially caused higher reliance on nursing homes. We shouldn’t need a pandemic to fix these problems.
Richard G. Frank, Ph.D., is a Margaret T. Morris Professor of Health Economics, Department of Health Care Policy, Harvard Medical School. Bianca K. Frogner, Ph.D., is an associate Professor in the Department of Family Medicine and Director of the Center for Health Workforce Studies in the School of Medicine at the University of Washington (UW). David C. Grabowski, Ph.D., is a professor of health care policy in the department of health care policy at Harvard Medical School. Jonathan Gruber is the Ford Professor of Economics at the Massachusetts Institute of Technology.
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