New York Attorney General Letitia James recently filed a lawsuit against The Villages, a nursing home in Albion, New York, for years of financial fraud that resulted in the abandonment of the “most basic functions of care” for the nursing home’s residents. An investigation conducted by the Office of the Attorney General found that from 2015 to 2021, the facility’s owners received $86.4 million in funding, “including millions in taxpayer dollars from Medicare and Medicaid, intended to provide quality healthcare.” Instead, the owners used those funds to cut staffing and to divert more than $18.6 million in payments to themselves — in all, more than 20 percent of the facility’s entire operating budget.
A press release from the Office of the Attorney General states that the facility’s financial scheme can be directly tied to its “reprehensible history of insufficient staffing.” It describes how residents of The Villages were forced to sit in their own urine and feces, recklessly medicated with psychotropics, and left malnourished and dehydrated. Residents developed sepsis, gangrene and “gaping” bed sores. The situation worsened during the COVID-19 pandemic. Management forced staff to come to work while sick, work longer hours, keep COVID cases secret, and delay or neglect quarantine and personal protective equipment (PPE) protocols. Ultimately, The Villages became home to “unnecessary and preventable deaths.”
But The Villages is not alone. The lawsuit is one of several forthcoming suits against nursing homes in the state. The case has, however, drawn renewed attention to the issues with the way long-term care facilities are funded — or not funded — in this country, and how lethal the fallout can be for their vulnerable residents.
Chronic underfunding means that these institutions face pervasive staffing shortages. In early December, a USA Today investigation found that thousands of nursing homes across the country have “flouted” federal staffing rules by going an entire day and night without a registered nurse on duty. Reporters found that only 4 percent of those facilities were cited by government inspectors; an even smaller percentage were fined. Last year, three-quarters of facilities had fewer nurses and aides than required by Medicare’s payment formula. High staff turnover is also a mainstay of the facilities, which are generally difficult and low-paying places of employment. Federal statistics show that “half of nursing staff — or more — turns over in a year.”
Elizabeth Wrigley-Field — an assistant professor at the University of Minnesota’s department of sociology and the Minnesota Population Center, who specializes in racial inequality in mortality and historical infectious disease — told Truthout that staffing shortages make nursing homes more dangerous for residents than they should be. “If you were trying to think about how to create a super spreader with as much force as possible,” she said, it would look like a nursing home. “We’ve designed a situation,” she added, “where the people who live in [these] facilities are at much greater risk of disease — not just COVID. And we pay the people who work in them so little that they often have to work multiple jobs,” putting staff at even higher risk of exposure. There is “no long-term solution,” she asserted, “that doesn’t involve those who work in care jobs being treated and paid much, much better than they are [now]. It’s completely predictable” that the current structure “results in a lot of needless deaths.”
Indeed, over the course of the pandemic, the COVID case fatality rate in nursing homes has been a staggering 12 percent. That means one in eight nursing home residents who have had a documented COVID illness have died because of it. Jeremy Faust, an emergency medicine physician who did the calculation, writes that even in the past month, around 250 residents have died each week of COVID.
Benjy Renton — Faust’s colleague and a research assistant at Ariadne Labs, where he focuses on COVID vaccine delivery and equity — told Truthout that residents’ COVID case fatality rate is outrageously high compared to that rate in the general population. In contrast to the rate for residents, the COVID case fatality rate for nursing home staff is 0.2 percent. But Faust still called 0.2 percent a “shocking figure.” It indicates that 1 in 500 health care workers in nursing homes, who have had a documented COVID case, have died from it.
These facilities haven’t gotten much safer in the last three years. Jennifer Nuzzo — a professor of epidemiology and the director of the Pandemic Center at Brown University’s School of Public Health — told Truthout that, notwithstanding the risks inherent to congregate living settings, age has always been the biggest risk factor for severe illness and death from COVID.
Early on in the pandemic, it became clear that residents of long-term care facilities were dying at disproportionate rates. Betsy McCaughey, a former lieutenant governor of New York who founded the Committee to Reduce Infection Deaths, famously called nursing homes “death pits” in early 2020. And analysis from Kaiser Family Foundation has found that over one-fifth of all U.S. COVID deaths have occurred in long-term care facilities.
Accordingly, older Americans were prioritized for vaccination at the start of the rollout in 2021. In nursing homes, especially, initial vaccine uptake was high: Over 85 percent of residents and staff completed a primary vaccine series. The death rate subsequently dropped. Wrigley-Field said the facilities became “relatively safer” that year, when so much “attention was paid to residents being vaccinated and making vaccines available. There was a lot of focus organizationally on making that happen. And that mattered: In 2021, the proportion of nursing home deaths was lower, and the age at death was lower.”
But over the course of this year, risks for older Americans have crept back up. In October, the Kaiser Family Foundation found that between April and July 2022, the number of monthly COVID deaths among people 65 and older had doubled — exceeding 11,000 for July and August. And a widely discussed analysis from the Washington Post recently showed that adults over the age of 65, who make up only 16 percent of the U.S. population, currently account for around 90 percent of COVID deaths.
Nuzzo said that because we now have “more tools to protect people,” the risk for younger people has generally decreased. This makes age-based disparities even starker. These days, Wrigley-Field added, “when you ask the question, ‘who is dying of COVID?’, you’re really asking the question, ‘who is old?’”
If we are to refuse to accept widespread excess deaths in older people, there is still much work to do — and also many avenues by which we can effect change. Nuzzo has repeatedly stressed that at-risk people need better access to treatments like Paxlovid. Others say useful transmission mitigation measures are being ignored; institutions might consider reinstituting universal masking and rapid testing. Unfortunately, the Centers for Disease Control and Prevention (CDC) released updated guidance for COVID control in health care settings in October, which included weakened requirements for PPE. At the time, experts thought the guidance would prove “disastrous for nursing home patients.” Faust, too, called it “terrible policy” — a “life-threatening” and “hostile act towards a vulnerable population.”
In the absence of those mitigation measures, residents’ safety has fallen to vaccines, and, subsequently, to boosters. Many experts point to the exceptionally low uptake of the new bivalent booster as a primary factor contributing to recent deaths in these facilities. Projections show that low levels of vaccination during a winter surge could result in 16,000 hospitalizations and 1,200 deaths per day by March 2023.
As the country confronts that winter surge — with many hospitals already at capacity with flu and RSV admits — less than 45 percent of nursing home residents are considered “up to date” on their COVID vaccines. Uptake is also variable across states — even across facilities. Seventy-four percent of nursing home residents in Vermont are up to date, but only 22 percent are in Arizona, where rates are the lowest in the country. These gaps create a “patchwork of immunity.”
The American Health Care Association/National Center for Assisted Living and LeadingAge have disputed some of the criticism leveraged against them on this issue. In November, the groups stated that nursing homes have done a “remarkable job” vaccinating residents. The percentage of residents who are up to date, they say, is “nearly four times higher” than the “dismal” coverage rate among the general population.
Still, considering that older Americans have been highly receptive to COVID vaccination — “seniors were among the first to get vaccinated and had high rates of uptake compared to other age groups” in 2021, according to Nuzzo — their low booster coverage is “puzzling” and “vexing” to her. This is not a population, she said, that needs to be argued with or convinced. Nuzzo wishes she knew more about why older Americans haven’t been getting boosted. “I would love to hear from people,” she said. “We collect these data so we can act. We need a better sense of the barriers so we can fix them.”
Nuzzo has hypotheses. Older Americans may be afraid to be alone after getting vaccinated, she said, since side effects can occur. Or they may be experiencing difficulty in accessing the booster. Other experts, like Renton, worry that people don’t know enough about its benefits. In October, Kaiser’s vaccine monitor survey showed that almost 40 percent of older Americans had heard “little or nothing” about the new bivalent booster, “and many were unsure whether the CDC had recommended it for them.”
The Biden administration is well aware of coverage gaps in this population. The administration recently announced a six-week $475 million campaign to raise vaccination rates among nursing home residents and staff. In a statement, the administration wrote that nursing homes with low vaccination rates would be under “close scrutiny” by state agencies, and would be responsible for enforcing requirements to offer vaccines and educate residents and staff about their benefits.
Guidance enforcement on its own will likely fall short. David Grabowski, a professor of health care policy at Harvard University, said facilities with low booster rates are likely facing “bigger challenges in addition to boosters.” Grabowski supports an approach that was popular during the initial rollout, in which nursing homes partnered with pharmacies to host clinics at nearly every nursing home. To achieve higher coverage rates, Grabowski said, “would clearly take federal dollars and a similar type of national pharmacy partnership” to the one that was created in 2021. Renton concurred, calling the partnerships “extremely successful.”
With “every subsequent rollout,” he lamented, “there’s been a drop off in vaccine coverage in staff and residents. Both of those groups are important.” Because residents are not “particularly mobile, most of the COVID that is ‘imported’ into nursing homes is likely coming from outside interactions that staff have with members of the community.” Yet the share of nursing home staff who are up-to-date on their boosters sits at just 23 percent, and only 10 percent of nursing homes have at least 75 percent of their staff up-to-date — making rates of vaccination among long-term care facility staff members the lowest of all health care professionals in the country.
Mass boosting — of both staff and residents — would indisputably bring down the rates of COVID illness and death in the nursing home population. But other, broader reforms must also be adopted. The Biden administration’s list of reforms, published in October, represents a good start. It includes new staffing requirements, increased financial transparency and programs to target “bad actors.” The administration has previously been critical of private equity involvement in nursing homes; private equity buyouts have been tied to resident deaths, lower levels of staffing, health and safety violations, and supply shortages. As expected, nursing homes are dealing with their share of consequences from nearly half a century of increasing corporatization of long term care.
Amid it all, profit-driven owners at facilities like The Villages in Albion have used funds distributed by Medicare and Medicaid to line their own pockets, in turn worsening conditions for both staff and the residents under their charge. But while investor-owned, for-profit nursing homes may not always defraud the federal government — as in the more extreme case of The Villages — they do always rely on profit extracted from residents, their families and their caretakers.
The administration’s statements may thus represent a kind of smokescreen. For-profit nursing homes and private equity involvement in long-term care facilities are surely not good, but the administration can’t simply root out “bad actors” in a system that allows any actor to make a profit off facilities purporting to provide care. Last week, Wrigley-Field asserted that there may be “a real ceiling on how safe these facilities can be” without more drastic changes to their funding structures. The administration needs to change course and reverse decades of government underfunding.
There is another way, of course. Countries like Japan, South Korea and Germany employ universal public long-term care insurance programs that cover a wide continuum of care. These programs are not perfect, and they face similar staffing challenges to their counterparts in the U.S. But unlike the American system, which struggles to provide comprehensive preventive health care — including, so importantly, COVID vaccination — these programs are geared to offer preventive, home and community-based care. The text of the Medicare for All Act of 2021 follows suit; the bill includes universal coverage of long-term care, and likewise prioritizes home- and community-based care over institutional care.
The U.S. lags behind countries with universal long-term care programs. But relatively speaking, those programs are young. Germany created its program in 1995. In Japan, the program is just 22 years old, developed in “response to public outcry against growing problems of neglect.” In the U.S., public outcry arrived long ago. Now, we’re waiting on the response.