The ACA repeal and its impact on nursing homes
Jeffrey M. Levine, M.D.
The public dialogue surrounding repeal of the Patient Protection and Affordable Care Act, also known as Obamacare, has made little mention of the nuts and bolts of the legislation that would be lost when it is gone. Many are unaware of sections designed specifically to improve nursing home care, and that repeal of the ACA would have a direct negative impact on quality of care in this arena.
The negative impact would occur not only from repeal of the sections that apply to long-term care, but also from cuts in Medicaid. The impact will be felt not only by patients and their families but by a substantial portion of the healthcare workforce.
As a geriatrician I am worried about the effect this repeal would have on a critical component of our healthcare system.
According to the CDC there were 15,600 nursing facilities in America housing 1.7 million residents in 2014, with over 50% suffering from Alzheimer's disease or other dementias. Nursing homes provide an important component of the healthcare continuum for frail elders, particularly those severely debilitated with cognitive impairment and at life's end. Drastic cuts to Medicaid will severely impact access to long-term care services and negatively affect quality of care to America's frailest and most vulnerable population – a position voiced by the American Geriatrics Society. Medicaid is the primary payer source for most nursing home residents, with more than 63% of residents having Medicaid as their primary payer in 2014.
Nursing homes are a major employer, providing nearly one million FTE's, comprised of registered nurses, licensed practical or vocational nurses, nursing assistants, and social workers. Massive cuts in Medicaid funding could devastate the healthcare job market particularly in nursing homes which are already stretched thin on staffing. Shortages already exist across the board for nurses and allied healthcare professionals, and this will be exacerbated by cuts in Medicaid. Staffing is an important structural variable in nursing homes that is directly related to clinical outcomes, and decreased staffing will certainly impair quality of care. Quality related adverse outcomes include unnecessary hospitalizations, weight loss, depression, fall-related injuries, infections, and skin breakdown.
A report by the Kaiser Commission on Medicaid and the Uninsured cites thirteen separate sections of the ACA that impact quality of care in nursing homes. Repeal of the ACA would remove initiatives including better nursing home transparency and accountability, improvements in the Nursing Home Compare website, mandatory compliance programs, standardized complaint forms that would facilitate tracking of complaints and determining complaint severity, and demonstration programs on culture change and information technology. Other programs include grants to support criminal and background check programs.
A New York Times investigative article in 2007 detailed how nursing homes owned by private investors cut expenses and staff, shielding themselves in court by creating complex corporate structures that obscure who controls the facilities. Section 6101 of the ACA promotes transparency for nursing home ownership, requiring facilities to disclose detailed information about their organization's structure including entities and individuals with major financial interest. Repeal of this law would make it more difficult for families to succeed in court when their loved ones suffer from adverse outcomes caused by neglect.
Nursing home staffing is a known quality indicator, and CMS's Nursing Home Compare website not only presents nurse staffing hours, but incorporates staffing into its Five-Star Quality Rating System. Prior to implementation of the ACA, staffing data were self-reported and generally unreliable. Section 6106 of the ACA imposed a program to collect staffing data directly from payroll records and cost reports using a uniform format developed by CMS. Repeal of the ACA will impair access to accurate data when families are searching for appropriate placement for their loved one.
Other components of the ACA that impact quality of care are worth mentioning, but there is not enough room to discuss them all. ACA Section 6114 authorizes demonstration projects to improve care to nursing home residents through culture change and information technology. Section 6201 expands a pilot program of the Medicare Prescription Drug, Improvement, and Modernization act of 2003 (MMA §307) to make states eligible for grants to design criminal background checks on nursing home employees.
For historical context, nursing homes have their historic origins in 19th century almshouses, which served as a last resort for impoverished people in old age. The nursing home industry grew rapidly in the 1960s and 1970s with passage of Medicare and Medicaid. By the close of the 1970s, the industry was mired in scandal, with many residents suffering consequences of over-sedation, misuse of physical restraints, and poor nutrition. A landmark Institute of Medicine study entitled Improving the Quality of Care in Nursing Homes published in 1986 concluded that effective regulation is essential to ensure high quality of care and quality of life in nursing homes. The authors argued strongly that market forces alone were insufficient to promote quality.
A direct result of the Institute of Medicine report was passage of the Nursing Home Reform Amendments, also known as the Omnibus Budget Reconciliation Act of 1987 (OBRA '87). This legislation was built largely around promotion of resident's rights, dignity, and quality of care. The Kaiser Commission points out that the Affordable Care Act was the first legislation since OBRA '87 that expands quality of care requirements for nursing homes, enforcing more stringent protection of residents' health, safety, and welfare.
Repeal of the ACA will be a setback in the movement toward better quality of care in nursing homes which contain America's frailest, most vulnerable and socially isolated population. In recent decades the nursing home industry has made strides in implementation of quality improvement measures, but there is still much work to be done. Mahatma Gandhi is quoted as saying, “A nation's greatness is measured by how it treats its weakest members.”
Legislation that decreases the quality of care for our elders is certainly not in line with a policy of “making America great again.”
Jeffrey Levine, M.D., is Associate Clinical Professor of Geriatrics and Palliative Medicine at the
Icahn School of Medicine at Mount Sinai.