Brendan W. Williams: Historic opportunity to shore up our aging nation’s long-term care

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IN THE Charles Dickens classic “Oliver Twist,” 9-year-old Oliver, living in a parish workhouse, has the temerity to ask for more gruel: “Please, sir, I want some more.”

Nursing home care can relate. Along with another $14 billion for airlines, the $1.9 trillion American Rescue Plan at least nodded to the needs of long-term care by providing an additional 10% in the federal participation rate in costs for home and community-based services (HCBS), which the Kaiser Family Foundation estimates could be an extra $11 billion. The only money directly appropriated toward nursing home care was for outbreak surge teams, which were no longer necessary even as the law was being debated, given vaccinations. Now, not to be outdone, the proposed $2.3 trillion American Jobs Plan would provide $400 billion for HCBS.

Not a single new dollar would be allocated to nursing home care under the American Jobs Plan, despite it being the sector most beset by COVID-19. All the platitudes about the plight of nursing home residents, and the heroism of nursing home staff, during the height of the pandemic, are not translating into meaningful support.

No one should begrudge a major investment in HCBS for those whose needs can be served at home. As children with disabilities, my own nephews benefitted from in-home care. The White House notes that “[c]aregivers — who are disproportionally women of color — have been underpaid and undervalued for far too long.” That is indisputably true. It is also indisputably true in the nursing home care sector, and for the same reason — Medicaid reimbursement has undervalued such workers.

According to Paraprofessional Health Institute data, 90% of nursing assistants in nursing homes are women, and 54% are people of color. Over a third of them rely upon public assistance, which is not surprising as the median hourly wage was $13.90 in 2019. Nursing home workers’ lives have value too. As do the lives of the residents they care for, the most medically fragile population in long-term care.

In Concord,long-term care advocates have had success looking beyond their silos and recognizing that the entire continuum of long-term care needs support, whether you are cared for at home, in an assisted-living facility or continuing-care retirement community, or in a nursing home. It is an interconnected system, where a HCBS client might need a nursing home placement, or a nursing home resident will need a HCBS spot upon rehabilitation and discharge. Congress and the Biden administration should take the same holistic approach.

Because Medicaid reimbursement has typically not recognized the Medicaid share-of-cost of capital costs, nursing homes have been left with aging infrastructure, with shared rooms and small communal spaces proving especially susceptible to respiratory virus spread. A modest investment from the federal government would certainly meet the Biden administration’s focus on infrastructure, and it would improve the living environments for thousands of New Hampshire residents in nursing homes.

Similarly, a permanent increase in the federal matching rate for nursing home care would ease the burden on states or, in the case of New Hampshire, county governments given the peculiarities of long-term care funding here.

A historic opportunity exists to shore up our aging nation’s long-term care system. We have seen urgent calls for action before, dating back to the Pepper Commission in 1990, that never resulted in change. Perhaps it will have taken the COVID-19 pandemic for us to recognize the value of our most vulnerable citizens, and those who care for them.