Nursing Homes and COVID-19: A Crisis on Top of a Crisis

• Author: Brian E. McGarry,David C. Grabowski
• Published date: 01 November 2021
• Date: 01 November 2021
• DOI: http://doi.org/10.1177/00027162211061509

ANNALS, AAPSS, 698, November 2021 137

DOI: 10.1177/00027162211061509

Nursing Homes

and COVID-19:

A Crisis on Top

of a Crisis

By

BRIAN E. MGARRY

and

DAVID C. GRABOWSKI

1061509ANN THE ANNALS OF THE AMERICAN ACADEMYNURSING HOMES AND COVID-19

research-article2021

The COVID-19 pandemic has caused a staggering

number of deaths and a great deal of suffering in U.S.

nursing homes. The spread of the virus across the coun-

try introduced a new emergency to a long-term care

sector that had already been in a state of crisis for mul-

tiple decades. Nursing homes have been underfunded

and understaffed for years, often delivering inadequate

care to their vulnerable residents, and they are financed

and regulated separately from the rest of the U.S.

health care system. During the pandemic, policy

responses at both the federal and state levels were

often slow and inadequate, partly due to a frayed infra-

structure that is the result of years of inattention from

policy-makers. We review the state of nursing home

care in the United States and the impacts of the pan-

demic, and we argue that a package of broader policy

and delivery reforms should be implemented to

improve the care of older adults that could help to pre-

vent future tragedy.

Keywords: nursing homes; COVID-19; pandemic;

Medicaid

COVID-19 devastated nursing homes in the

United States. They were called the pan-

demic’s “ground zero” (Barnett and Grabowski

2020), and outbreaks in these facilities were

termed a “perfect storm” (Ouslander and

Grabowski 2020). Residents of nursing homes

and assisted living facilities account for less

than 1 percent of the overall population but

have seen about 5 percent of cases and 32 per-

cent of all COVID-19 deaths (Kaiser Family

Foundation 2021). This concentration of cases

Brian E. McGarry is an assistant professor of medicine

in the Division of Geriatrics and Aging at the University

of Rochester. His research focuses on the care of older

adults and their interactions with the health and long-

term care systems.

David C. Grabowski is a professor of health care policy

at Harvard Medical School. His research examines the

economics of aging with a particular focus on long-term

care and postacute care.

Correspondence: grabowski@med.harvard.edu

138 THE ANNALS OF THE AMERICAN ACADEMY

in long-term care facilities was similar in other countries, including Belgium,

Spain, and Britain (Birnbaum and Booth 2020). During 2020 alone, 1.3 million

(or 42 percent) U.S. nursing home residents were diagnosed with either COVID-

19 or likely COVID-19 (Office of Inspector General 2021). Nursing home mor-

tality increased by nearly one-third during 2020 relative to the prior year,

equating to 169,121 additional deaths (Office of Inspector General 2021).

Nursing homes did not begin the pandemic from a position of strength. Many

nursing homes have a long history of inadequate staffing and quality-of-care

problems (Grabowski 2019). For example, the average U.S. nursing home has an

annual staff turnover rate above 100 percent, with some exceeding 200 percent

and 300 percent (Gandhi, Yu, and Grabowski 2021). Facilities often rely on the

use of inappropriate antipsychotic medications and physical restraints to manage

residents. Moreover, these facilities are often not very home-like, and care is not

directed by the residents. Finally, many direct caregivers are underpaid and

undervalued in these settings. For this reason, the pandemic in nursing homes

has been called a “crisis on top of a crisis” (Israelsen-Hartley 2020). In this article,

we first describe the long-standing issues in nursing home care before turning to

the impact of the COVID-19 crisis on nursing homes. We conclude by consider-

ing a series of reforms that will improve nursing homes in a postpandemic world.

The Crisis before the Crisis

Prior to the pandemic, roughly 15,400 Medicare- or Medicaid-certified nursing

homes existed in the United States, caring for nearly 1.3 million residents on a

given day. Nursing homes broadly care for two types of individuals: short-term

patients recovering from a hospital stay and long-stay residents who will require

assistance for the remainder of their lives. The short-term (or postacute) patient

stays are generally covered by Medicare, while the long-stay residents are typically

covered by Medicaid. Some long-stay residents pay privately out of pocket, while

a small share have their care covered by private long-term care insurance. Roughly

two-thirds of nursing homes are for-profit owned, one-fourth are nonprofit

owned, and the remainder are government owned. Roughly 6 percent of facilities

are hospital based. Private equity ownership and investment in nursing homes has

increased in recent years (Stevenson and Grabowski 2008; Gupta etal. 2020).

The COVID pandemic has caused a staggering amount of death and suffering

in U.S. nursing homes. Yet in many ways this global event merely shed light on a

national failure to fully support the care of older adults and those with disabilities

unable to live independently. The spread of the virus across the country intro-

duced a new emergency to a long-term care sector that has been in a state of

crisis for multiple decades. For years, nursing homes have been underfunded and

understaffed, delivering inadequate care to their vulnerable residents that is

NOTE: The authors acknowledge funding for this work from the Robert Wood Johnson

Foundation. The views expressed herein are those solely of the authors and do not necessarily

reflect the views of the funder.