Why have so many nursing home patients died from coronavirus nationwide? The key to answering that question lies in many of the nation’s leading politicians’ policy responses to the pandemic. Most notably, Gov. Andrew Cuomo (D-N.Y.) issued an ill-conceived order requiring nursing homes to accept COVID-positive patients.
Forcing institutions to accept positive patients “seeded” coronavirus in nursing homes, where it spread like wildfire. Although Cuomo eventually rescinded that measure, the decision was too late to save the thousands of nursing home patients who died before it could undo the damage initially wrought. Last Thursday, in a display of callous indifference to the loved ones of deceased patients desperate for answers, Cuomo called the focus on his order a “shiny object” and “pure politics.”
But the high death toll in nursing homes also reflects underlying policy differences that preceded coronavirus: Some states house more individuals in nursing homes than others. These disparities, coupled with the inherent infection risk present in nursing homes, should provide states new motivation to accelerate the movement of seniors and individuals with disabilities out of institutional facilities wherever and wherever possible.
Differences Among States
As of 2017, more certified nursing facilities operated in Florida than in New York. But the larger average size of New York’s facilities means the state has nearly 35 percent more nursing home beds than Florida — even though Florida has 35 percent more seniors older than age 65 than New York does. New York’s nursing homes average 185.1 beds per facility, the highest in the country by far. With a larger nursing home population and larger facilities, the virus had more room to rampage than in other states with smaller facilities and smaller nursing home populations.
During the past several weeks, the growing death toll in nursing homes prompted state and federal officials to surge resources to facilities, from testing to personal protective equipment to infection control specialists. But policymakers should ask a more fundamental question: Why do we still have so many individuals in nursing homes at all? The spread of COVID is likely reduced by home-based care while providing an environment most patients prefer, and often at lower costs than nursing homes.
Over the past several decades, Congress and states have begun to redirect Medicaid spending from institutional care towards home and community-based services. From 1988 to 2016, the percentage of Medicaid long-term care spending directed toward home-based services grew from 10 percent to 57 percent.
But in some states, the powerful nursing home lobby still thwarts policy efforts that would empty facility beds. As of 2016, for one example, New York spent more on institutional care than Florida and California did combined.
A Better Solution
By contrast, Rhode Island’s global compact, approved in January 2009, consolidated myriad Medicaid waivers into a single effort increasing access to home-based care. The state’s experiment succeeded: The number of individuals receiving institutional care declined 6.2 percent, while those receiving community-based care rose by 25.8 percent. Rhode Island’s rebalancing towards community-based care helped keep overall Medicaid spending flat during a time of enrollment growth, and did so by increasing access to care, not limiting it.
States like Rhode Island that have moved individuals needing long-term care out of nursing homes wherever possible have the potential to see fewer incidents of mass deaths. Indeed, vulnerable populations will still need to take precautions to avoid COVID regardless. But moving seniors out of congregate settings like nursing homes would minimize the risk of a “super-spreader” incident in which a single individual infects dozens or even hundreds of patients.
Congress Inhibits Reform
With its ability to reduce health-care spending and the risk of infection, the coronavirus pandemic should have given states added incentive to transition Medicaid beneficiaries into home-based care — had Congress not gotten in the way. Legislation passed in March giving states an increase in the federal Medicaid match conditioned the additional dollars on states not limiting benefits. As a result, more aggressive attempts by states to direct spending to community-based care — for instance, by capping nursing home slots, or requiring beneficiaries to try home-based care first — could jeopardize states’ additional federal matching funds.
When I served on the congressional Commission on Long-Term Care in 2013, one of my colleagues often said the next person who told him she wanted to enter a nursing home would be the first person to express such a desire. That adage holds as true today as it did seven years ago, and this truth should compel states to promote home and community-based care wherever possible at all times. During the coronavirus pandemic, however, such a transition won’t just give seniors better care in a way that saves health-care costs — it could save seniors’ lives.