The COVID-19 pandemic has been devastating to America’s most vulnerable elders, in long-term care facilities. The New York Times calculates that staff and residents at nursing homes and other long-term care developments account for more than a third of coronavirus-related deaths in the United States.
In some states, the toll is higher. Residents in Minnesota long-term care facilities represent less than 1 percent of the population yet comprise about 80 percent of COVID-19 deaths in the state.
“The elderly are the most susceptible to high risk, bad outcomes,” says Robyn Stone, senior vice president at Leading Age, an organization that advocates for nonprofit aging service providers.
If ever there was a time to reform policies, practices and financing for long-term care facilities — especially nursing homes — this is it.
The epicenter of COVID-19
Nursing homes have been the tragic epicenter of COVID-19. There, residents are often frail, coping with multiple medical conditions, living in crowded buildings, making them highly susceptible to the coronavirus. Low-wage caregivers typically work at multiple nursing homes, hiking their odds of exposure to the virus.
Yet the trauma from the pandemic extends beyond nursing homes to the wider ecosystem of senior living and senior care.
COVID-19 starkly and cruelly reveals what the elder care community has long warned: America’s long-term care system is badly frayed, poorly financed and vastly inadequate to meet the needs and ensure a good quality of life for America’s growing population of older adults — especially lower-income elders.
“This crisis has hopefully made it clear to the general public and public officials that we have routinely underfunded long-term care for poor elders,” says Robert Kramer, founder and president of Nexus Insights, a COVID-19 inspired advisory firm for rethinking aging. “I think this has brought out into the open a lot of public attitudes and public policy that sees people over a certain age as expendable.”
Why the elder care system is so troubled
One reason America’s elder care system is so troubled: its ecosystem is sprawling and complex.
On the payments side of the equation, Medicare covers few long-term care costs (although private Medicare Advantage plans often offer some services). Medicaid, the federal/state program that pays for long-term care services, requires impoverishment to qualify. Most Medicaid money pays for institutional care (think nursing homes), rather than in-home care. Assisted living, continuing care communities and similar facilities have a private-pay system; some well-off residents and families tap into long-term care insurance policies to pay for services.
Middle-income families have often found their earnings and savings inadequate to meet the steep costs of long-term care even before the pandemic further reduced household finances. The annual cost of a private room in a nursing home (national median) is over $100,000 a year, according to the latest Genworth Cost of Care Survey. Only about 10 precent of Americans 65 and older have long-term care insurance.
Most older adults prefer aging in their homes with family support, but that isn’t always a practical or desirable choice.
A pandemic effect: worsening economics for long-term care
Due to the pandemic, the economics of long-term care will worsen.
For one thing, some families have become reluctant to put aging parents into congregate living facilities, fearful of the higher health risks from COVID-19 and worried that parents will be quarantined alone there.
For another, the price tag for living in a long-term care facility will go up. Expenses are on the rise with managements scrounging for Personal Protection Equipment (PPE), coronavirus tests, cleaning supplies and staff.
Take the experience of Brookdale Senior Living, which operates over 800 communities nationwide. Management in a recent earnings call said it had spent $10 million in the first quarter on its COVID-19 response.
How to fix things
There is some recognition of the problem, though.
For example, Senators Bob Casey (D-Pa.) and Sheldon Whitehouse (D-R.I.) have offered a bill to provide $20 billion to help states, nursing homes and intermediate-care facilities (usually small, group homes) contain COVID-19. Leading Age has called on Congress to allocate $100 billion in its next relief package to support aging services. And the House of Representatives Democrats’ new coronavirus relief bill, The HEROES Act, would let Medicare health care providers receive compensation for the additional COVID-19 costs they’re incurring. HEROES is an opening marker in a debate about the next relief fund and at least some relief may make it to President Trump’s signature.
Yet many of the expenses associated with battling the coronavirus will become critical costs of doing business in a post-pandemic environment. What’s more, paying for higher long-term care expenses will be tough for financially drained households and tax-starved governments.
The bottom line? Business as usual for long-term care facilities isn’t an option.
“There will come a time when we’ll see the pandemic in the rearview mirror,” says Kramer. “There will not come a time when we will return to the old normal.”
The clear and present danger is that numerous senior living and senior care operators go out of business and that policymakers reduce their support even more.
That said, the unprecedented disruption also opens up the tantalizing opportunity for society and policymakers to address the kind of reforms that would improve the living standards and lifestyle of an aging population, most notably the large ranks of lower-and middle-income elderly Americans.
“This has shaken things up enough that reform could happen,” muses Stone. “I think that the Phoenix rises from the ashes,” she adds, laughing.
A look into the future of long-term care facilities
What might reform look like?
Congregate living won’t disappear as an option, but the settings will likely be redesigned with physical and mental health considerations in a post-pandemic society.
Two of the changes experts expect: no more shared rooms and reconfigured living spaces for comfort during periodic shelter-in-place moments. Private balconies or small private patios, for instance, would let residents safely get outdoors during quarantines.
Also likely: The health care system will increasingly blend into senior care communities, from increased use of telemedicine (rather than in-person doctor’s appointments) to infectious disease control systems.
“There are changes we can make to make them [long-term care facilities] safer,” says Sara Marberry, a health care design knowledge expert and marketing consultant. “There are a lot of technology and products for infectious control in health care already; it will now permeate all kinds of senior living, including independent living.”
Long-term care analysts also think congregate living managements will — finally — devote bigger budgets to training their professional staff and personal care workers. That way, the workers will be trained to be more knowledgeable about how best to keep infections at bay.
“We have learned from this that we need highly trained people, particularly real infection control and a whole system of care,” says Stone.
Investments in technology will be essential. As telehealth and telemedicine become routine coming out of the crisis, they’ll both require good broadband access and devices in long-term care facilities.
How to pay for it all
How to pay for better design, workforce training and technology? There is no shortage of good blueprints, including policy models developed by the Long-Term Care Financing Collaborative and the Bipartisan Policy Center. Another place to look: Washington State’s universal public long-term care insurance benefit for residents which became law last year. Countries like Germany and Japan offer approaches to emulate, too.
There’s no exaggeration in saying that the choices we make about how we treat our elders gets to the core of society’s values. In recent weeks, too many callous remarks have dismissed older adults and their pandemic-related risks of death as sad, but nothing to get worked up over.
But rather than framing the care of elders through the lens of dependency, think about how much they add to society.
“I hope we’ll generate a really good vision of older adults in our society,” says Kramer. “What they contribute to our society. Not a dependency model.”
The question now is, will we take advantage of the pandemic-induced upheaval in long-term care to create a better life for an aging population?
That’s a challenge worth embracing.