The handwritten doctor’s order was just eight words long, but it solved a problem for Dundee Manor, a nursing home in rural South Carolina struggling to handle a new resident with severe dementia.
David Blakeney, 63, was restless and agitated. The home’s doctor wanted him on an antipsychotic medication called Haldol, a powerful sedative.
“Add Dx of schizophrenia for use of Haldol,” read the doctor’s order, using the medical shorthand for “diagnosis.”
But there was no evidence that Mr. Blakeney actually had schizophrenia.
Antipsychotic drugs — which for decades have faced criticism as “chemical straitjackets” — are dangerous for older people with dementia, nearly doubling their chance of death from heart problems, infections, falls and other ailments. But understaffed nursing homes have often used the sedatives so they don’t have to hire more staff to handle residents.
one in 150 people.
Schizophrenia, which often causes delusions, hallucinations and dampened emotions, is almost always diagnosed before the age of 40.
“People don’t just wake up with schizophrenia when they are elderly,” said Dr. Michael Wasserman, a geriatrician and former nursing home executive who has become a critic of the industry. “It’s used to skirt the rules.”
refuge of last resort for people with the disorder, after large psychiatric hospitals closed decades ago.
But unfounded diagnoses are also driving the increase. In May, a report by a federal oversight agency said nearly one-third of long-term nursing home residents with schizophrenia diagnoses in 2018 had no Medicare record of being treated for the condition.
hide serious problems — like inadequate staffing and haphazard care — from government audits and inspectors.
One result of the inaccurate diagnoses is that the government is understating how many of the country’s 1.1 million nursing home residents are on antipsychotic medications.
According to Medicare’s web page that tracks the effort to reduce the use of antipsychotics, fewer than 15 percent of nursing home residents are on such medications. But that figure excludes patients with schizophrenia diagnoses.
To determine the full number of residents being drugged nationally and at specific homes, The Times obtained unfiltered data that was posted on another, little-known Medicare web page, as well as facility-by-facility data that a patient advocacy group got from Medicare via an open records request and shared with The Times.
The figures showed that at least 21 percent of nursing home residents — about 225,000 people — are on antipsychotics.
The Centers for Medicare and Medicaid Services, which oversees nursing homes, is “concerned about this practice as a way to circumvent the protections these regulations afford,” said Catherine Howden, a spokeswoman for the agency, which is known as C.M.S.
“It is unacceptable for a facility to inappropriately classify a resident’s diagnosis to improve their performance measures,” she said. “We will continue to identify facilities which do so and hold them accountable.”
significant drop since 2012 in the share of residents on the drugs.
But when residents with diagnoses like schizophrenia are included, the decline is less than half what the government and industry claim. And when the pandemic hit in 2020, the trend reversed and antipsychotic drug use increased.
A Doubled Risk of Death
For decades, nursing homes have been using drugs to control dementia patients. For nearly as long, there have been calls for reform.
In 1987, President Ronald Reagan signed a law banning the use of drugs that serve the interest of the nursing home or its staff, not the patient.
But the practice persisted. In the early 2000s, studies found that antipsychotic drugs like Seroquel, Zyprexa and Abilify made older people drowsy and more likely to fall. The drugs were also linked to heart problems in people with dementia. More than a dozen clinical trials concluded that the drugs nearly doubled the risk of death for older dementia patients.
11 percent from less than 7 percent, records show.
The diagnoses rose even as nursing homes reported a decline in behaviors associated with the disorder. The number of residents experiencing delusions, for example, fell to 4 percent from 6 percent.
A Substitute for Staff
Caring for dementia patients is time- and labor-intensive. Workers need to be trained to handle challenging behaviors like wandering and aggression. But many nursing homes are chronically understaffed and do not pay enough to retain employees, especially the nursing assistants who provide the bulk of residents’ daily care.
Studies have found that the worse a home’s staffing situation, the greater its use of antipsychotic drugs. That suggests that some homes are using the powerful drugs to subdue patients and avoid having to hire extra staff. (Homes with staffing shortages are also the most likely to understate the number of residents on antipsychotics, according to the Times’s analysis of Medicare data.)
more than 200,000 since early last year and is at its lowest level since 1994.
As staffing dropped, the use of antipsychotics rose.
Even some of the country’s leading experts on elder care have been taken aback by the frequency of false diagnoses and the overuse of antipsychotics.
Barbara Coulter Edwards, a senior Medicaid official in the Obama administration, said she had discovered that her father was given an incorrect diagnosis of psychosis in the nursing home where he lived even though he had dementia.
“I just was shocked,” Ms. Edwards said. “And the first thing that flashed through my head was this covers a lot of ills for this nursing home if they want to give him drugs.”
Homes that violate the rules face few consequences.
In 2019 and 2021, Medicare said it planned to conduct targeted inspections to examine the issue of false schizophrenia diagnoses, but those plans were repeatedly put on hold because of the pandemic.
In an analysis of government inspection reports, The Times found about 5,600 instances of inspectors citing nursing homes for misusing antipsychotic medications. Nursing home officials told inspectors that they were dispensing the powerful drugs to frail patients for reasons that ranged from “health maintenance” to efforts to deal with residents who were “whining” or “asking for help.”
a state inspector cited Hialeah Shores for giving a false schizophrenia diagnosis to a woman. She was so heavily dosed with antipsychotics that the inspector was unable to rouse her on three consecutive days.
There was no evidence that the woman had been experiencing the delusions common in people with schizophrenia, the inspector found. Instead, staff at the nursing home said she had been “resistive and noncooperative with care.”
Dr. Jonathan Evans, a medical director for nursing homes in Virginia who reviewed the inspector’s findings for The Times, described the woman’s fear and resistance as “classic dementia behavior.”
“This wasn’t five-star care,” said Dr. Evans, who previously was president of a group that represents medical staff in nursing homes. He said he was alarmed that the inspector had decided the violation caused only “minimal harm or potential for harm” to the patient, despite her heavy sedation. As a result, he said, “there’s nothing about this that would deter this facility from doing this again.”
Representatives of Hialeah Shores declined to comment.
Seven of the 52 homes on the inspector general’s list were owned by a large Texas company, Daybreak Venture. At four of those homes, the official rate of antipsychotic drug use for long-term residents was zero, while the actual rate was much higher, according to the Times analysis comparing official C.M.S. figures with unpublished data obtained by the California advocacy group.
make people drowsy and increases the risk of falls. Peer-reviewed studies have shown that it does not help with dementia, and the government has not approved it for that use.
But prescriptions of Depakote and similar anti-seizure drugs have accelerated since the government started publicly reporting nursing homes’ use of antipsychotics.
Between 2015 and 2018, the most recent data available, the use of anti-seizure drugs rose 15 percent in nursing home residents with dementia, according to an analysis of Medicare insurance claims that researchers at the University of Michigan prepared for The Times.
in a “sprinkle” form that makes it easy to slip into food undetected.
“It’s a drug that’s tailor-made to chemically restrain residents without anybody knowing,” he said.
In the early 2000s, Depakote’s manufacturer, Abbott Laboratories, began falsely pitching the drug to nursing homes as a way to sidestep the 1987 law prohibiting facilities from using drugs as “chemical restraints,” according to a federal whistle-blower lawsuit filed by a former Abbott saleswoman.
According to the lawsuit, Abbott’s representatives told pharmacists and nurses that Depakote would “fly under the radar screen” of federal regulations.
Abbott settled the lawsuit in 2012, agreeing to pay the government $1.5 billion to resolve allegations that it had improperly marketed the drugs, including to nursing homes.
Nursing homes are required to report to federal regulators how many of their patients take a wide variety of psychotropic drugs — not just antipsychotics but also anti-anxiety medications, antidepressants and sleeping pills. But homes do not have to report Depakote or similar drugs to the federal government.
“It is like an arrow pointing to that class of medications, like ‘Use us, use us!’” Dr. Maust said. “No one is keeping track of this.”
published a brochure titled “Nursing Homes: Times have changed.”
“Nursing homes have replaced restraints and antipsychotic medications with robust activity programs, religious services, social workers and resident councils so that residents can be mentally, physically and socially engaged,” the colorful two-page leaflet boasted.
Last year, though, the industry teamed up with drug companies and others to push Congress and federal regulators to broaden the list of conditions under which antipsychotics don’t need to be publicly disclosed.
“There is specific and compelling evidence that psychotropics are underutilized in treating dementia and it is time for C.M.S. to re-evaluate its regulations,” wrote Jim Scott, the chairman of the Alliance for Aging Research, which is coordinating the campaign.
The lobbying was financed by drug companies including Avanir Pharmaceuticals and Acadia Pharmaceuticals. Both have tried — and so far failed — to get their drugs approved for treating patients with dementia. (In 2019, Avanir agreed to pay $108 million to settle charges that it had inappropriately marketed its drug for use in dementia patients in nursing homes.)
‘Hold His Haldol’
Ms. Blakeney said that only after hiring a lawyer to sue Dundee Manor for her husband’s death did she learn he had been on Haldol and other powerful drugs. (Dundee Manor has denied Ms. Blakeney’s claims in court filings.)
During her visits, though, Ms. Blakeney noticed that many residents were sleeping most of the time. A pair of women, in particular, always caught her attention. “There were two of them, laying in the same room, like they were dead,” she said.
In his first few months at Dundee Manor, Mr. Blakeney was in and out of the hospital, for bedsores, pneumonia and dehydration. During one hospital visit in December, a doctor noted that Mr. Blakeney was unable to communicate and could no longer walk.
“Hold the patient’s Ambien, trazodone and Zyprexa because of his mental status changes,” the doctor wrote. “Hold his Haldol.”
Mr. Blakeney continued to be prescribed the drugs after he returned to Dundee Manor. By April 2017, the bedsore on his right heel — a result, in part, of his rarely getting out of bed or his wheelchair — required the foot to be amputated.
In June, after weeks of fruitless searching for another nursing home, Ms. Blakeney found one and transferred him there. Later that month, he died.
“I tried to get him out — I tried and tried and tried,” his wife said. “But when I did get him out, it was too late.”
Andrea Jones hadn’t yet settled on a date to retire from her customer service job at United Airlines when Newark airport started looking like a ghost town in March 2020. After 28 years with the carrier, she still loved her work. But by the end of that month, she had hung up her blue uniform for the last time. She is still struggling with a sense of loss.
“I wasn’t at all ready to leave,” she said. “It hit me right between the eyes.”
Ms. Jones, 68, of East Windsor, N.J., retired to protect the health of her husband, George, who has multiple myeloma, a form of cancer. Fortunately, the Joneses had a nest egg, and United offered a retirement package that enabled her to keep their health insurance.
Patricia Scott has not been so lucky. Ms. Scott, a special-education teacher in Stockton, Calif., retired in January to preserve her own health. A grandmother of 10, she survived breast cancer in 2016; her oncologist told her she couldn’t risk catching Covid-19 by returning to the classroom. Now, at age 66, she is on financial quicksand. “My income is half what it was,” she said. She is single and in debt. “I’m stressed, I’m depressed and I’m terrified.”
For many of the nearly three million workers ages 55 to 70 who have left their jobs since March 2020, retiring during the pandemic has inflicted two traumas. Like Ms. Jones and Ms. Scott, most felt they were forced out of work before they wanted to go, said Teresa Ghilarducci, a professor of economics and policy analysis at the New School for Social Research. Among that subset, the majority, like Ms. Scott, were financially unprepared, Ms. Ghilarducci said.
research from the New School, far more older workers retired during the pandemic than during other recessions. After the 2008 financial crisis, for example, 1.9 million older workers left the labor force in the first three months of the recession. In the first three months of the pandemic last year, 2.9 million left the work force. The latest data shows that 1.7 million of the newer wave of retirees left despite financial uncertainty, Ms. Ghilarducci said.
Their departures generally were not a bid for a few extra years of bird-watching. “A lot of people were pushed out of their jobs,” Ms. Ghilarducci said; she attributed that push partly to age discrimination. “It used to be that employers would let the ones they just hired go first in a recession, but this time older people who have been in their jobs the longest have been hit hardest.”
Lack of enforcement of anti-discrimination laws was a factor, she said. So was what some employers saw as a rare opportunity created by the pandemic to get rid of older workers, who are perceived to be less productive and more expensive.
Regardless of the reason, the new army of reluctant retirees, disproportionately made up of Black workers and those who lack a college degree, according to June data from the New School, is in trouble. One key reason: Debt rates among Americans 65 and older are the highest they’ve ever been, Ms. Ghilarducci said. And they are likely to rise as more people are forced to draw down their assets to make ends meet. Collecting Social Security earlier than anticipated will add to their vulnerability, since claiming earlier will permanently reduce their benefits.
Even for people with a financial safety net, the hurdles can be significant. “There’s a lot of stress that comes with having retirement forced on you,” said Malcolm Ethridge, a financial adviser in Washington who has several newly out-of-work older clients. “It takes time to get past the disruption.”
Jovan Johnson, a certified financial planner in Atlanta, said Ms. Scott and others in her situation should start looking for a pro bono financial adviser who can help make sense of their money. “There are a lot of us out there who will help people out for free during a crisis,” he said. He recommends searching sites like the XY Planning Network.
The primary benefit of sitting down with a professional may be relief from panic, he said. But the 15 new retirees who have contacted him for pro bono help since the pandemic started, among them nurses and teachers, have also gained a better understanding of how to manage limited funds. “Everybody deserves to have a plan,” he said.
Pen and Brush after 23 years as executive director, the stress started last year, when she contracted Covid-19 and spent several weeks in an intensive care unit. She was not psychologically ready to retire, but because she has still not fully recovered, she felt she had to. “I was one of those people who was going to have to be wheeled out of there, I loved it so much,” she said.
Now she is adjusting to what she said was a more limited routine. Sunday nights and Mondays flummox her the most. “It’s like when you have that dream where you have a final exam and you’ve never been to class, or you forget your locker combination. I keep thinking, I have to go to work.” Instead, she takes walks with her husband, Wallace Munro, a retired actor, and visits the grocery store more than she thought she would ever want to.
“It’s something to do,” she said. “You have to restructure your life when something like this happens to you. It’s so easy to get depressed.”
Managing money in a sudden retirement
Mr. Johnson, the financial planner, offered tips on juggling your income and expenses when you’re thrust into joblessness with little warning.
Make sure that you do not have any old pension or 401(k) money out there from previous employers. People who have rolled over retirement accounts from previous employers often forget about them.
Don’t feel guilty for taking Social Security early — especially if you have no other option. You can begin claiming your benefits as early as age 62. However, the downside to claiming before your full retirement age (you can look it up on the Social Security website) is that your total monthly payments will be permanently reduced. If your income is below a certain threshold, your full Social Security payments might be tax-free.
Use Social Security payments for your nondiscretionary, fixed expenses and retirement assets for discretionary expenses, such as travel and entertainment.
Bridge the gap to Medicare, because the age of eligibility is 65. Consider plans under the Affordable Care Act. Typically, if your income is low enough, you may receive premium tax credits and other benefits if you choose a plan on the marketplace.
If Social Security and retirement savings cannot sustain your lifestyle, it’s time to consider Medicaid, Supplemental Security Income and similar programs.
The Biden administration is moving in a new direction. It is trying to help low-income Americans by pushing for direct cash assistance in addition to expanding health insurance.
Each is a laudable goal. But doing both at once may not be feasible, as lawmakers raise concerns about the total price tag of Biden’s plans.
If the administration has to make hard choices, it can do more to help the poor by prioritizing cash transfers over expanded health insurance. That’s because cash helps recipients directly, while health insurance would pay mainly for care that many uninsured people were already receiving at low or no cost.
For over a decade, health insurance expansions have dominated the budget and politics of legislation directed toward the poor. In 2019, the government spent more than $600 billion on Medicaid — the major health insurance program for low-income Americans. This was more than 10 times the amount spent on the largest cash transfer program, the earned-income tax credit.
legislation enacted in March brought a welcome shift in focus toward cash benefits. Among its temporary provisions were about $100 billion in increased payments to low-income families with children and $15 billion in stepped-up wage subsidies for low-income workers, overshadowing the approximately $35 billion in new spending for health insurance.
The evidence indicates that for the low-income recipients of these programs, cash transfers will provide a greater bang for the government’s buck. Two separate studies that my collaborators and I conducted found that, on average, low-income adults would benefit more from a dollar in cash than a dollar of government spending on health insurance.
These kinds of comparisons are inherently difficult. One approach we took to measuring the value of health insurance to recipients was to see how much they were willing to pay for it. Another was to estimate the effects of such insurance on their lives, like improved health and increased economic security. Neither approach is airtight.
But they gave very similar answers: The benefit of Medicaid coverage received by a newly insured adult is less than half what that coverage costs taxpayers, which is about $5,500 a year.
The reason is simple: The uninsured already receive a substantial amount of health care, but pay for only a very small portion of it, especially when their medical bills are high.
estimated that 60 percent of government spending to expand Medicaid to new recipients ends up paying for care that the nominally uninsured already receive, courtesy of taxpayer dollars and hospital resources. In other words, from the recipient’s perspective the alternatives are $5,500 in cash or only about 40 percent of that — $2,200 — in health insurance benefits, on top of the care they were already receiving.
The United States has a longstanding tradition of providing free medical services to the indigent. Hospitals emerged in the 18th century largely to care for those with no other sources of help. In modern times, federal and state governments have enacted a grab bag of policies to help defray some of the costs incurred by hospitals and clinics in providing humanitarian care.
The result is today’s health care safety net for the uninsured. It is grossly inadequate and inefficient. It needs a radical overhaul.
But in the meantime, the direct benefits from expanding insurance to the low-income uninsured are, paradoxically, limited by the imperfect patches currently in place. Hospitals are major beneficiaries of health insurance expansions, which reduce their financial burdens and increase their profit margins.
Health insurance has always been an important financial tool for hospitals. During the Great Depression, they pioneered the first widespread health insurance in the United States to help ensure payment for provided care.
More recently, in 2006, when Senator Mitt Romney was the Republican governor of Massachusetts, he embraced the state’s health insurance expansion — which became the blueprint for Obamacare — as a way to reduce the costs that uninsured patients imposed on hospitals and taxpayers. Hospitals later used similar logic in lobbying for Medicaid expansions under Obamacare and against their repeal.
Of course, the newly insured have also benefited greatly from health insurance expansions. On this point, the evidence from Obamacare is in, and the research results are clear: Medicaid coverage is better than the safety-net care available to the uninsured.
saved lives. They also increased access to medical care and reduced medical debt, which can impose substantial financial and emotional pain on patients and their families, even though most of it is never repaid. Covering some of the remaining 30 million Americans who are still uninsured would most likely produce similar benefits.
But people in need also benefit greatly from cash. And there is evidence that cash transfers can also save lives.
In addition, a large body of work shows that wage subsidies to low-income workers with children help lift their families out of poverty, increase economic self-sufficiency, and improve their health and well-being. A recent experiment found that wage subsidies very similar to the ones that were temporarily expanded in March also increase employment and earnings for low-income adults without dependent children. Likewise, direct cash transfers provide important benefits to families and their children, whose academic achievement and physical and mental health can improve as a result.
In an ideal world, everyone would have health insurance and sufficient income. But in the real world, budgetary and political constraints often force wrenching trade-offs.
There are powerful moral imperatives for making sure that everyone has adequate medical care, as well as sufficient income for their nonmedical needs. It’s hard for economists to weigh competing moral imperatives.
But we can, at least, stack dollars on scales. And the good done by cash transfers tips the scale in their favor.
The Biden administration is now trying to make permanent its temporary expansions of both cash subsidies and health insurance. If forced to prioritize how best to help those who are struggling economically — either because of the coronavirus pandemic or from longer-term, structural obstacles — it’s time to recognize that cash is more effective than insurance.
Amy Finkelstein is the John and Jennie S. MacDonald professor of economics at the Massachusetts Institute of Technology.
Millions of low-income Americans became eligible on Wednesday for an emergency discount on high-speed internet service and devices to get online, an effort aimed at providing relief to families that have struggled during the pandemic as school, work and health care have moved online.
The Federal Communications Commission’s subsidy program, the Emergency Broadband Benefit, can be used for $50 monthly discounts for individuals on SNAP or Medicaid, recipients of Pell grants, and families with children on free and reduced-price lunch plans. Low-income households on tribal lands can apply for $75 in monthly broadband subsidies. The program also allows for a one-time $100 subsidy for a laptop or tablet.
The F.C.C. said 825 broadband providers have agreed to offer the discounts.
The program, which Congress approved $3.2 billion for late last year, is one of several efforts to bring broadband internet to all American homes. The F.C.C. earlier this week also approved a $7.2 billion program to give students high-speed internet access through schools and libraries. President Biden has promised to make broadband affordable and available for all and has proposed a $100 billion effort to connect every rural and low-income home to high-speed internet service.
The Emergency Broadband Benefit program comes late in the pandemic, with schools and workplaces beginning to open again. The delay was largely because of wrangling over details of the subsidies in Congress and at the F.C.C. during the Trump administration. And it’s unclear what will happen once the one-time emergency benefit fund runs out.
The program will end either when the $3.2 billion fund is depleted or six months after the Department of Health and Human Services declares an end to the pandemic.
“High-speed internet service is vital for families to take advantage of today’s health, education, and workplace opportunities,” Jessica Rosenworcel, the acting chair of the F.C.C., said in a statement. “And the discount for laptops and desktop computers will continue to have positive impact even after this temporary discount program wraps up.”
Even before the pandemic began 14 months ago, nursing homes had become the source for rampant, antibiotic-resistant infections. The facilities also faced systemic problems like high turnover among nursing home staff and the gaming of the federal government’s rating system, which made it hard for families to judge the quality of homes.
For years, federal health officials and some insurers have tried to encourage more stay-at-home care, and the pandemic has created a sense of urgency.
“It’s really changed the paradigm on how older adults want to live,” said Dr. Sarita Mohanty, the chief executive of the SCAN Foundation, a nonprofit group focused on issues facing older adults. The vast majority of those adults would prefer to stay at home as they age, she said.
“What’s happened is a welcome sort of market correction for nursing homes,” said Tony Chicotel, a staff attorney for California Advocates for Nursing Home Reform in San Francisco. Some families, he said, “ended up agreeing to a nursing home without giving it a lot of deliberation.” But after trying home care during the pandemic, many families found keeping an older relative at home was a viable alternative, he said.
Nursing homes rose from the almshouses in England and America that cared for the poor. In the United States, passage of the Social Security Act in 1935 provided money for states to care for the elderly. Thirty years later, the Medicaid program expanded funding, making long-term care homes central to elder care, said Terry Fulmer, the president of the John A. Hartford Foundation, an advocacy group for older adults. “If you pay the nursing homes, that’s where you go,” Dr. Fulmer said.
It wasn’t until the 1970s that some programs began to pay for home care, and the number of nursing home residents nationwide started to slowly decline, with occupancy levels in recent years flattened to about 80 percent, according to data from the Kaiser Family Foundation.
President Biden’s $400 billion proposal to improve long-term care for older adults and those with disabilities was received as either a long overdue expansion of the social safety net or an example of misguided government overreach.
Republicans ridiculed including elder care in a program dedicated to infrastructure. Others derided it as a gift to the Service Employees International Union, which wants to organize care workers. It was also faulted for omitting child care.
For Ai-jen Poo, co-director of Caring Across Generations, a coalition of advocacy groups working to strengthen the long-term care system, it was an answer to years of hard work.
“Even though I have been fighting for this for years,” she said, “if you would have told me 10 years ago that the president of the United States would make a speech committing $400 billion to increase access to these services and strengthen this work force, I wouldn’t have believed it would happen.”
knocking millions of women out of the labor force — or deplete their resources until they qualify for Medicaid.
Whatever the limits of the Biden proposal, advocates for its main constituencies — those needing care, and those providing it — are solidly behind it. This would be, after all, the biggest expansion of long-term care support since the 1960s.
“The two big issues, waiting lists and work force, are interrelated,” said Nicole Jorwic, senior director of public policy at the Arc, which promotes the interests of people with disabilities. “We are confident we can turn this in a way that we get over the conflicts that have stopped progress in past.”
And yet the tussle over resources could reopen past conflicts. For instance, when President Barack Obama proposed extending the Fair Labor Standards Act of 1938 to home care workers, which would cover them with minimum-wage and overtime rules, advocates for beneficiaries and their families objected because they feared that states with budget pressures would cut off services at 40 hours a week.
“We have a long road ahead of passing this into law and to implementation,” Haeyoung Yoon, senior policy director of the National Domestic Workers Alliance, said of the Biden proposal. Along the way, she said, supporters must stick together.
half of adults would need “a high level of personal assistance” at some point, typically for two years, at an average cost of $140,000. Today, some six million people need these sorts of services, a number the group expects to swell to 16 million in less than 50 years.
In 2019, the National Academy of Social Insurance published a report suggesting statewide insurance programs, paid for by a dedicated tax, to cover a bundle of services, from early child care to family leave and long-term care and support for older adults and the disabled.
This could be structured in a variety of ways. One option for seniors, a catastrophic insurance plan that would cover expenses up to $110 a day (in 2014 dollars) after a waiting period determined by the beneficiary’s income, could be funded by raising the Medicare tax one percentage point.
Mr. Biden’s plan doesn’t include much detail. Mr. Gleckman of the Urban Institute notes that it has grown vaguer since Mr. Biden proposed it on the campaign trail — perhaps because he realized the tensions it would raise. In any event, a deeper overhaul of the system may eventually be needed.
“This is a significant, historic investment,” Mr. Espinoza said. “But when you take into account the magnitude of the crisis in front of us, it’s clear that this is only a first step.”
The pandemic has intensified a spotlight on long-running questions about how communities can do a better job supporting seniors who need care but want to live outside a nursing home.
The coronavirus had taken the lives of 181,000 people in U.S. nursing homes, assisted living and other long-term care facilities through last weekend, according to the Kaiser Family Foundation — 33 percent of the national toll.
The occupancy rate in nursing homes in the fourth quarter of 2020 was 75 percent, down 11 percentage points from the first quarter, according to the National Investment Center for Seniors Housing & Care, a research group. The shift may not be permanent, but this much is clear: As the aging of the nation accelerates, most communities need to do much more to become age-friendly, said Jennifer Molinsky, senior research associate at the Joint Center for Housing Studies at Harvard.
“It’s about all the services that people can access, whether that’s the accessibility and affordability of housing, or transportation and supports that can be delivered in the home,” she said.
Mark Miller reports for The New York Times:
A major shortage of age-friendly housing in the United States will present problems for seniors who wish to stay in their homes. By 2034, 34 percent of households will be headed by someone over 65, according to the Harvard center. Yet in 2011, just 3.5 percent of homes had single-floor living, no-step entry and extra-wide halls and doors for wheelchair access, according to Harvard’s latest estimates.
Medicare does not pay for most long-term care services, regardless of where they happen; reimbursement is limited to a person’s first 100 days in a skilled nursing facility. Medicaid, which covers only people with very low incomes, has long been the nation’s largest funder of long-term care. From its inception, the program was required to cover care in nursing facilities but not at home or in a community setting. “There’s a bias toward institutions,” said Judith Solomon, a senior fellow specializing in health at the Center on Budget and Policy Priorities.
The PACE provider manages all of a person’s health care needs that are covered by Medicare or Medicaid. “It becomes your form of health care coverage,” said Peter Fitzgerald, executive vice president for policy and strategy at the National PACE Association, a membership and advocacy organization.
States decide whether to offer PACE programs; currently 30 have programs serving about 55,000 people, Mr. Fitzgerald said.
Where change is happening
Some states and regions are moving to address the needs of their aging citizens.
In January, Gov. Gavin Newsom released a master plan for aging for California. It calls for creating, over the next decade, millions of housing units for older residents, one million high-quality caregiving jobs, and inclusion goals such as closing the digital divide and creating opportunities for work and volunteering. Colorado, Massachusetts, Minnesota and Texas have already established master plans, and a number of other states are working on them.
California’s plan also calls for a new state office focused on finding ways to innovate using Medicare funds, especially for low-income, chronically ill seniors who also participate in Medicaid.
“We think this can really help our state by bringing together medical and nonmedical services for people who want to live well in the place they call home,” said Gretchen E. Alkema, vice president of policy and communications at the SCAN Foundation, a nonprofit focused on elder care that has worked with California and other states on age-friendly models.
In the Atlanta metropolitan area, which began tackling these issues head-on in 2002, one in five residents will be 65 or older by 2050, according to the Atlanta Regional Commission, a planning organization. The group has responded by developing a “lifelong communities initiative” to raise awareness in local government of the need for housing that is affordable and convenient to sidewalks, shopping and transportation.
Atlanta and four suburbs have joined an AARP-sponsored network of age-friendly communities, and several city neighborhoods have created plans.
Twelve years ago, the U.S. government introduced a powerful new tool to help people make a wrenching decision: which nursing home to choose for loved ones at their most vulnerable. Using a simple star rating — one being the worst, five the best — the system promised to distill reams of information and transform an emotional process into one based on objective, government-blessed metrics.
The star system quickly became ubiquitous, a popular way for consumers to educate themselves and for nursing homes to attract new customers. During the coronavirus pandemic, with many locked-down homes unavailable for prospective residents or their families to see firsthand, the ratings seemed indispensable.
But a New York Times investigation, based on the most comprehensive analysis of the data that powers the ratings program, found that it is broken.
The ratings program, which is run by the U.S. Centers for Medicare & Medicaid Services, or C.M.S., relies on a mix of self-reported data from more than 15,000 nursing homes and on-site examinations by state health inspectors.
years of warnings, the system provided a badly distorted picture of the quality of care at the nation’s nursing homes. Many relied on sleight-of-hand maneuvers to improve their ratings and hide shortcomings that contributed to the damage when the pandemic struck.
More than 130,000 nursing-home residents have died of Covid-19, and The Times’s analysis found that people at five-star facilities were roughly as likely to die of the disease as those at one-star homes.
The pandemic laid bare the flaws in the government rating system.
The state health inspections do little to penalize homes with poor records of preventing and controlling infections. From 2017 to 2019, The Times found, inspectors cited nearly 60 percent — more than 2,000 — of the country’s five-star facilities at least once for not following basic safety precautions, like regular hand washing. Yet they earned top ratings.
In San Bernardino, Calif., inspectors wrote up Del Rosa Villa for four different infection-control violations. It kept its five stars. Ninety residents at the 104-bed facility have contracted the coronavirus, and 13 have died.
Del Rosa Villa officials didn’t respond to requests for comment.
Life Care Centers of Kirkland, Wash., the first nursing home in the United States to have documented coronavirus cases, was found in 2019 to have weak infection controls, despite its five stars. State inspectors wrote it up for failing to “consistently implement an effective infection control program.”
Thirty-nine of the facility’s residents have died from Covid-19. The home has 190 beds.
Leigh Atherton, a Life Care spokeswoman, said that citation was the only lapse in infection control that inspectors had identified over 32 previous visits. She said the home quickly fixed the problem.
If the rating system worked as intended, it would have offered clues as to which homes were most likely to have out-of-control outbreaks and which homes would probably muddle through.
That is not what happened.
The Times found that there was little if any correlation between star ratings and how homes fared during the pandemic. At five-star facilities, the death rate from Covid-19 was only half a percentage point lower than at facilities that received lower ratings. And the death rate was slightly lower at two-star facilities than at four-star homes.
A facility’s location, the infection rate of the surrounding community and the race of nursing home residents all were predictors of whether a nursing home would suffer an outbreak. The star ratings didn’t matter.