Health Care/Joan Retsinas

Nursing Homes, Or Pricing Grandma

By now many cities are facing the nursing home catastrophe: some homes, unable to hire enough staff to meet the statutory requirements, are letting beds go empty — or, worst case, are closing. In 2022, 129 nursing homes closed. Analysts predict that as many as 400 may soon close.

The bogey: staff. Or, more precisely, the lack of staff.

The “care” in homes depends upon staff, both trained nurses and less-trained assistants. Staff give medications, change linens, wash residents, serve and feed meals — the arduous essential “bed and body” work. A good nursing home, moreover, offers more than that: it gives residents a community, a feeling of safety, a sense that staff care. Residents benefit from kindness and attention. And as the number of staff plummets, so too does the individualized care, the attention, and the sense of community.

To date, “staff” means people. There is no substitute, not technology, not AI.

Nursing homes concede the benefits of trained staff. Ironically, the Biden Administration has pushed for more stringent staffing requirements.

But the homes point to a pragmatic reality: they cannot hire enough staff to meet the statutory requirements.

One plausible solution is to reduce the number and training of staff. Some nursing home owners are arguing for just that remedy. The thinking goes: if we need fewer trained staff, then we can open more beds, stay open. With the current staffing requirements, we cannot hire enough people. We risk closing, leaving residents with few recourses.

Yet that solution presages a return to the old days of scandals-without-end. Can fewer staff deliver better care? The past decades scream “no.” Exposes like “Tender Loving Greed” by Mary Adelaide Mendelson (1974), “Too Old, Too Sick, Too Bad” by Frank E. Moss (1977) and “Unloving Care: The Nursing Home Tragedy” by Bruce Vladeck (1980) detailed the horrors. Fewer staff lead to more accidents, more medication errors, more pressure ulcers, more call buttons that remain unanswered. The nursing home owners’ plea for fewer staff yields a sad message: poor care is better than no care.

The retort from owners is that there simply are no nurses, or nursing assistants, in the labor market. All the job fairs haven’t worked.

That assumption obscures the reality of labor force economics. There are not enough nurses, and nursing assistants, willing to work for the wages that the nursing homes pay. Up the wages and benefits, provide health insurance, give paid vacations, establish pension plans — and see what happens. The training program for nurses, nursing assistants, dietary aides, and housekeepers is not long: we have a network of community colleges geared to train staff. The jobs are difficult; and fewer staff make the jobs more difficult, if one nurse must grapple with the demands of too many residents, all needing help.

If we make those difficult jobs lucrative, if we have sufficient staff so that the burden does not fall on one or two people, then we will have applicants. Indeed, if we structure mobility into those jobs, with paid educational credits, we can enable nursing assistants to climb an occupational ladder to be nurses.

Residents who live in nursing homes are trapped. Each nursing home closure plunges residents into limbo, waiting for a placement somewhere somehow, hoping that “advocates” can stay the closing of their home. Residents cannot simply go to another home: those other homes face their own staff shortages, are often full, with waiting lists. Residents cannot go “home” to family members (many residents have outlived their friends and families). They need care too skilled, too constant for assisted living placements. And most residents, receiving Medicaid, cannot afford to hire help to live at home.

Our legislators hold the key to the solution. On the federal level, budget-cutters are debating how much they can shave from the Medicare skilled nursing budget. On the state level, legislatures are flaunting their efforts to pare their Medicaid budgets, to spare taxpayers money. Of course, those pared budgets, on both levels, translate into staff salaries. More money will keep the nursing homes open.

But first legislators at both levels must price Grandma’s needs against the myriad other demands on the budgets. And taxpayers must look beyond their pocketbooks to the older people in their midst; in fact, taxpayers should look a few decades into the future, when they, too, may need nursing homes.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email joan.retsinas@gmail.com.

From The Progressive Populist, June 15, 2023

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