An Absence of Tender Loving Care: The Nursing Home Dilemma

When an aging individual can no longer manage on his or her own and cannot afford home health care, which usually is paid for out-of-pocket, entering a nursing home is often the only solution. Acknowledging the need to enter such a facility is a decision that people put off for as long as possible for a number of reasons. Moving into a nursing home means accepting a loss of independence and recognizing that one is probably nearing the end of one’s life, but perhaps most frightening is the fear of the kind of insufficient, even harmful and abusive care some of those homes provide.

A report released by the Government Accountability Office this week gives credence to those fears. It confirms that “little seems to have changed at the worst-performing homes. The Bush administration rarely uses its authority to deny payment to homes with a history of compliance problems and typically imposes fines far less than the maximum of $10,000 a day.”

In defense of the failure to impose the full penalties for noncompliance, federal health officials warn that some homes might close if they were to face stiffer penalties. That is not a reason a civilized nation can accept for allowing the inhumane treatment of the most fragile of its citizens.

Looking at the demographics indicates the problems could grow worse. According to the National Center for Health Statistics, approximately 1.6 million people aged 65 and older live in nursing homes in the United States. Of those, 15 percent are aged 65 to 74, 37 percent are 75 to 84, and 45 percent are over 85. Moreover, the group over 85 is the fastest growing segment of the population: in 2010, it will make up 2 percent of the population, but by 2050, 5 percent of the population will be over 85—increasing the size of the group needing care.

With the aging of the population a given, this nation should focus on policies that can help to achieve two goals: reducing the number of people who end up in nursing homes (thus lessening demand and allowing market forces to eliminate the worst) and solving the problems that create poor care for those who have no alternative.

We can reduce the number of people in nursing homes by putting in place policies aimed at enabling them to continue to live at home for as long as possible. At this time, Medicare pays nothing for assisted living, and Medicaid pays very little, leaving individuals to pay virtually all expenses involved out-of-pocket. Since more than half of those over eighty-five have incomes below $15,000, programs designed to pay some or all of those costs are necessary. A possible solution for those with children or other family who could help but cannot afford to lose income by doing so would be to ease the costs of caretaking through steps such as providing a reasonable tax credit for family caregivers, providing direct cash payments to family members who give such care, and encouraging more long-term care insurers to offer the option of selecting a family member or friend to care for the policyholder in his or her own home.

One of the main reasons nursing homes often provide inadequate care is that they lack properly trained staff. In the case of registered nurses, the Department of Health and Human Services projects that the shortage of some 218,800 full-time registered nurses in 2005 will increase to 405,800 in 2010; 683,700 in 2015; and a startling 1,016,900 in 2020. This shortage is due in part to the number of trained nurses who are boomers and reaching retirement age and in part to the shortage of nursing school faculty because of the increasing salaries available to nurses with advanced degrees who choose to work in hospitals. Last August, the New York Times reported that nursing schools had to turn away “almost 150,000 qualified applicants in 2005—up 18 percent over the previous year.”

Congress has begun to address this problem in the Nurse Reinvestment Act passed in 2002, which includes a government loan repayment program that provides those who want to become nurses scholarships in exchange for at least two years of service in a health care facility with a critical shortage. It also makes provision for nurses seeking advanced degrees to qualify for loans that can be cancelled if they agree to take faculty positions for a period of time. However, funding for this program must be reauthorized yearly, which makes clear public support for such funding essential.

In addition, alleviating the shortage of other nursing home workers as well as providing home health care aides to help people who could live at home with some assistance will require increasing the number of visas for low-skilled workers from abroad, a move that has met strong opposition, with Congress cutting the number of visas for such workers last year from 400,000 to 200,000.

Although the problem of poor nursing homes has been serious and worsening for years, perhaps now, with the large number of baby boomers facing the possibility of needing such homes, is the time to push for action, the time when support can be found to make spending on this problem a priority.