The tsunami of baby boomers is a long-told story, yet we continue to resist discussion about its impact on a humanistic level for fear of revealing our own vulnerabilities. We covet youth, health and vibrancy and shield our eyes from the truth that those are all fleeting. America has not been great at caring for our aged or disabled; we lack financial and human resources, opportunity, and perhaps even the desire to do so. With dual parent working families, single parents busily working and raising children, and the financial erosion of caretaking capacity, Americans leverage community resources to meet care needs.

The pandemic has unveiled many of our system failings as a country. One that goes woefully unspoken is the tragedy that occurs daily in our long-term care facilities. In a recent conversation with a nursing home caregiver a heart-wrenching story was shared about a simple request by a thirsty resident for a glass of ice water. She was unable to get that glass of water for the resident due to the extraordinary needs of all the residents and being the only caregiver on the unit at that time. We are talking about the basics to sustain life. Problems in this industry have existed for years, however these have been exacerbated as nursing homes became the epicenter for the pandemic. Long-term care residents account for about a third of all COVID deaths, yet only totally 5% of all U.S. COVID cases. Poor staffing ratios have been linked to the inability to protect residents from this rampant virus, and social isolation from support persons negatively impact the physical and mental health of our most vulnerable to a shameful level.

In care facilities, nursing assistants provide daily physical care for the aged and disabled, including help with bathing, using the restroom, grooming, eating, mobility, and providing the caring and social support they need for a healthy existence. It is exhausting work under the best conditions. During a pandemic it is soul shaking. Nursing assistants have historically been subjected to poor wages and benefits, inadequate staffing ratios, and the stresses of caregiving; forcing nursing assistants out of the profession to work other jobs resulting in a high turnover rate and the vicious cycle of understaffing. When a local barista job offers higher wages, better hours, tuition reimbursement and minimal risk to health and safety it is no wonder caregivers quickly leave the profession for alternate opportunities. As nursing assistants are leaving the profession, the aging baby boomer generation is requiring more care at greater numbers. This imbalance is not sustainable.

At the root of this problem is inadequate Medicaid reimbursement for long-term care stays. In the late 1990s, Medicaid reimbursement was “reformed,” leaving states to determine what the long-term care reimbursement rate should be. As state budgets tightened, reimbursements fell far short of the rate of inflation, leaving the industry, nursing assistants and residents in a precarious and rapidly declining position for the last two decades. That, coupled with the crippling financial effects of the pandemic, highlights the gap between what it costs to care for residents and what is reimbursed; it is a crevasse that can no longer be filled with creative staffing solutions, continued wage stagnation or cutting benefits. With 60% of long-term care stays funded by Medicaid, this trend is eroding the safety nets for our most vulnerable.  As of August 2020, over half of our nursing homes reported operating at a loss, and two thirds were projecting the inability to stay open another year at the current pace.

Aside from the financial implications, inadequate Medicaid reimbursement for long-term care directly results in poor staffing ratios, which in turn results in substandard care. When quality care is compromised staff are left feeling guilty and frustrated for not providing the care they were trained to give. Poor staffing ratios also mean rationed care; there is only time for the barest of basics. This problem of insufficient staffing also directly translates to residents feeling rushed and guilty when asking caregivers for even the basic amount of help, leaving them isolated, anxious, and depressed.  These conditions set the stage to create a self-fulfilling prophecy of continued rationing, poor quality of care and basic needs going unmet.

Without long-term care facilities and properly trained caregivers our most vulnerable in society would struggle to exist. In care facilities that maintain poor staffing levels resulting in substandard care, our most vulnerable may be able to achieve a fundamental existence by receiving the basics of care, however, care facilities with proper reimbursement and in turn adequate staffing can provide quality care to our most vulnerable, offering a home in which to thrive as opposed to simply survive.

Carrie Jarosinski

Carrie L. Jarosinski is a registered nurse, certified nurse educator, thought leader, and author of our CNA family of titles. She began her career as a nursing assistant and then as a registered nurse in long-term care. She then moved on to work in public health, focusing on children with special healthcare needs, childhood lead poisoning prevention, and prenatal health. In 2006, Carrie started her teaching career as adjunct faculty in the Nursing and Nursing Assistant Programs at Mid-State Technical College (MSTC). In 2007, she became the Lead Nursing Assistant Instructor and Program Director at MSTC and is now the lead faculty in the Health and Wellness Promotion Program. In 2015, Carrie authored Essentials of Certified Nursing Assisting textbook and workbook. She also completed a Doctorate of Nursing Practice in Systems Leadership with a focus on rural food desert conditions from Walden University.