WORKFORCE
In 2016, well before an apocalyptic global pandemic wreaked havoc on our nation’s health care workforce, the Obama Administration acknowledged that mandating nursing home staff ratios would have the effect of “stifling innovation, and would not result in the improved quality and person-centered care that we seek in facilities.”
Further, the Obama Administration warned, presciently, in rejecting a suggested 24/7 registered nurse (RN) requirement, that “geographic disparity in supply could make such a mandate particularly challenging in some rural and underserved areas.”
In its inexplicable efforts to resurrect what the Obama Administration rejected, the Biden Administration commissioned a study finding no “clear evidence basis for setting a minimum staffing level” and warning “nursing homes are currently very challenged in hiring and retaining direct care workers, because of workforce shortages and competition from higher-paying agency positions.”
Yet the Administration went ahead and issued a mandate proposal anyway that includes, among other things, a 24/7 RN requirement, even though the federal government has separately published a report showing “a projected shortage of 78,610 full-time equivalent (FTE) RNs in 2025” – which will impact all health care providers.
The administration magnanimously offsets what it estimates is the $4.06 billion annual cost of its proposal with a one-time investment of $75 million in the nursing home workforce. There are roughly 15,000 nursing homes nationwide, so that funding is around $5,000 per facility. This federal pittance is equal to the signing bonus for a single RN at the Merrimack County Nursing Home!
The national accounting firm of Clifton-LarsonAllen LLP projects that under the proposed mandate, nationally, nursing homes would have to hire 102,154 additional full-time employees, and that, currently, only eight New Hampshire facilities would meet the requirements. It finds the unfunded cost to be $6.8 billion a year.
Unaccountably, the proposed mandate completely fails to count licensed practical nurses, even though federal data shows that in 2022 there were 700 LPNs working in New Hampshire nursing homes, making an average of $31.72 an hour, versus 470 registered nurses. The care they provide is invaluable, and it’s shocking they are of no value to the Biden Administration.
A quick survey my association conducted immediately following the proposal’s release found no nursing home not already meeting the mandate’s ratios expected it would be able to add enough additional full-time staff. Instead, a majority would limit admissions to meet the ratio, a plurality could meet it only through price-gouging nurse staffing agencies, and one-tenth would close.
It should be noted that if nurse staffing agencies are used, runaway costs could only be met if the state reimburses the cost for the majority of nursing home residents on Medicaid, which would require either sizable county property tax increases — as in New Hampshire counties fund long-term care — or diverting resources away from our vital home and community-based settings, which would be disastrous for policy aims of aging in place.
Given an existential staffing crisis, New Hampshire nursing homes are already turning away those needing care to keep quality high for their current residents. Two county homes each have wait lists of over 100 prospective residents. One, Cheshire County’s Maplewood Nursing Home, is only operating 100 out of its 150 beds, and fears it could only operate 50 if this mandate went through. Further access denials would be a nightmare for a state with the nation’s second-oldest population.
Because nursing home access issues are already jamming up hospitals with discharge-ready patients for which they receive no payment, the American Hospital Association opposes a nursing home staffing mandate.
With no licensed staff out there to hire, the New Hampshire Veterans Home already has had to contract with three out-of-state nurse staffing agencies just to serve veterans, and the National Association of State Veterans Homes opposes the Biden Administration mandate.
Finally, our entire congressional delegation has expressed its strong concerns with the mandate. Our two senators signed a bipartisan letter stating “a one-size-fits-all staffing mandate significantly undermines access to care for patients, particularly in rural communities.” New Hampshire makes the list of the nation’s 10 most rural states— it’s actually more rural than Iowa. What may, or may not, work in New York City would not work in, say, Coös County.
The Biden Administration cannot ask the impossible of New Hampshire nursing homes — by many metrics the nation’s best. It must rescind its care-destroying, irrational proposal.
Brendan Williams is the president and CEO of the New Hampshire Health Care Association.
