Although nursing home residents comprise only 1 percent of the U.S. population, they account for more than 35 percent of all Covid-19 deaths. By the end of March, there were 179,000 deaths from Covid-19 among residents and staff of nursing homes and other long-term care facilities. These numbers might not seem surprising, given that nearly all illnesses hit older people harder than the young. Just look at flu season. Despite the majority of elderly people getting a flu vaccine, 75 percent to 80 percent of flu deaths are among those 65 and older. Still, the high number of elderly deaths due to Covid-19 isn’t entirely a function of age. Beginning in March 2020, most “congregate facilities,” which include nursing homes, assisted living and long-term care facilities, were locked down tight, with no visitors allowed. We’ve all seen photos of residents confined to their rooms and families standing outside so they could at least wave at grandma through the window. Staff were told to stay home if they had any Covid-19 symptoms.
Yet even with all that, the virus ripped through these facilities. Why didn’t these measures work? Two reasons: first, these facilities have a long history of poor infection control that public health agencies have been unable to curb, well before the pandemic. Second, congregate care companies often pay horribly, and rarely offer health insurance or paid sick leave to their frontline workers.
By the end of May 2020, half of all cases among the elderly were brought in by “direct care workers,” such as nurses, nursing assistants, physical therapists, maintenance and kitchen staff. These people are among the most essential workers—and some of the worst paid. In 2019, their median hourly wage was just $12.80. Nearly half live in low-income households. More than half receive public assistance. The vast majority are women and three in five are people of color.
Add poor pay to no sick leave or health insurance, and many direct care workers can’t afford to stay home when they are sick. Jen Hurst is a critical care speech pathologist in Kansas City, Missouri. For 15 years, she’s worked for the same long-term care company, which has never given her a full-time job or benefits. She can’t afford to take time off when she’s sick. When she developed symptoms that seemed like Covid-19, she briefly thought about going into work before deciding to stay home—and that required tapping her family’s modest savings.
Direct care workers also spread Covid-19 by working at multiple facilities. Keith Chen, a professor of behavioral economics at UCLA, led a clever study using anonymized cell phone data to track the movements of direct care workers. Roughly half of all deaths could be traced to staff moving between facilities. “Lockdowns had a surprisingly modest effect,” says Chen. In addition, most nursing homes rely on agencies to provide subs when staff are sick. That means workers were moving from site to site and multiple spreaders might fill in for one sick staffer.
For-profit ownership of nursing homes exacerbates the dangers. With fewer staff than nonprofit facilities, for-profit nursing homes tend to hire more part-time and casual workers and have higher turnover rates. They also had a 10 percent higher death rate even before the current pandemic. Between 2004 and 2016, approximately 70 percent of nursing homes in the U.S. were run as for-profit entities, and that accounted for more than 20,000 excess deaths. More recently, a study found that for-profit homes in Connecticut had 60 percent more cases of Covid-19 and deaths per licensed bed than nonprofit homes.
Canada’s experience proves the link between low pay for direct care workers and Covid-19 outbreaks. A study led by Michael Liu, a Rhodes scholar and entering Harvard Medical School student, found that even though two Canadian provinces, British Columbia and Ontario, issued a directive instructing direct care workers to choose a single facility to minimize risk, there were divergent results. British Columbia paid workers the difference in lost income caused by sticking to one facility. Ontario did not and workers there, Liu discovered, were less likely to abide by the directive, making them more likely to transfer the virus from facility to facility. British Columbia also issued its directive three weeks sooner.
Waiting for Vaccine Herd Immunity
Now that Covid-19 vaccinations are well underway, it would be a mistake to think congregate care residents are out of danger. The spread of the virus by poorly paid workers remains a threat. That’s because the vaccines are unlikely to work as robustly in the elderly as they appear to do in those under 65. That means older facility residents remain vulnerable, especially as variants proliferate.
The first thing to do is to reverse public health budget cutting. Timothy Killian, spokesperson for the Life Care facility in Kirkland, Washington, where COVID-19 was first identified in the U.S., told the American Association of Retired Persons, “We all grew up with these movies about pandemics in which the government vans swoop in and take control. As the situation escalated and the facility went into lockdown and people started dying, I kept expecting some type of coordinated response, but we saw nothing of that nature.” By contrast, Liu says that close ties between public health authorities and long-term care facilities in British Columbia allowed the province to immediately send in “swat teams” to troubleshoot and assist with the pandemic.
Second, we have to strengthen oversight. Kezia Scales is director of health policy at PHI, a national nonprofit organization based in New York that “works to transform eldercare and disability services.” She says oversight of long-term care services is “so dispersed across providers and settings, that it has hindered any comprehensive or timely response across all states…[We] don’t have a consistent model across states and no consistent response across various types of facilities.”
Third, congregate care workers need better pay and better treatment. Once again, actions taken by British Columbia are instructive. Even before the pandemic began, the province was paying facilities more per resident than Ontario, and most of that pay goes towards staff. In addition, only 34 percent of facilities in British Columbia operated on a for-profit basis compared with 58 percent in Ontario, leaving even less money in Ontario for workers. In the U.S., says Scales, “We need a sustainable commitment to the workforce. If Medicaid [were to] set a wage floor for direct care workers, then non-Medicaid employers would likely have to follow suit. Workers need enough money to get by.”
It will help if Congress passes President Biden’s $2 trillion American Jobs Plan, which earmarks $400 billion for nursing home and community-based care for disabled and elderly Americans. The funds, according to the White House, will create “new jobs and [offer] caregiving workers a long-overdue raise, stronger benefits, and an opportunity to organize or join a union and collectively bargain.” Research shows that increasing the pay of direct care workers enhances their financial security, improves productivity, and increases the quality of care they provide.
The White House should push for mandatory paid sick leave, a difficult goal politically, rather than assuming that collective bargaining will guarantee that sick workers stay home or that funds given to patients and facilities will end up in staff pockets. Still, the Biden plan is an important down payment towards curbing staff-spread contagions. After more than a year of politicians and advertisers paying homage to frontline, essential workers, it’s time to take action to help the low-paid workers taking care of our elderly. They need real help, for their sake and for ours.