A nurse refusing a vaccine shot

Kimberly Marselas

Skilled nursing providers on Tuesday cheered the federal government’s decision to revoke its COVID-19 vaccine mandate for healthcare workers.

The controversial rule, issued in November 2021, had split nursing home owners, operators and frontline staff, mirroring a nasty national divide over voluntary vaccination campaigns, masking and other COVID protocols.

It was enacted only after a January 2022 U.S. Supreme Court decision, and went into effect as providers warned that mandating shots would make it even more challenging to recruit healthcare staff.

That debate has raged on. On April 24, more than 50 House members urged the Centers for Medicare & Medicaid Services to lift the mandate, arguing that it continues to “exacerbate healthcare staffing shortages and jeopardize patient access to quality care, especially in rural and underserved parts of the country.”

Monday night’s surprise announcement by the Biden administration that officials “will start the process to end their vaccination requirements” at CMS-certified healthcare facilities was met with a warm welcome in the long-term care halls of America. Many recognized the COVID is moving toward becoming an endemic disease, one nursing homes are much more capable of detecting, preventing and treating.

LeadingAge president and CEO Katie Smith Sloan, whose organization has been a strong advocate for vaccine access, said Tuesday that “the vaccine mandate is no longer needed.”

“Our country is in a very different place now than in summer of 2021, when the mandate was initially proposed,” she said, referring to the administration’s first attempt to issue a nursing home-only mandate. 

Vaccines still in play

But she also acknowledged that vaccines must remain a widely used tool for both nursing home staff and residents, echoing strains of the White House announcement.

“Whether or not a mandate is in place, there is no question that COVID-19 vaccines are a safe and effective defense against the virus, which disproportionately impacts older adults and the people who care for them,” Sloan added.

Others said uncertainty about the timing of this week’s announcement was countered by improving COVID metrics across the US.

“Given what we have been through the last few years, it’s hard to say when it would be the right time, but science is proving that the US has fewer SARS CoV-2 cases, fewer hospitalizations, and fewer deaths over time,” said Steve LaForte, director of corporate affairs and general counsel for Cascadia Healthcare, which operates 45 facilities in the northwest and southwest. “Personally, I wasn’t sure this was the right time to end the PHE, especially relative to the waivers, but we knew at a certain point for political reasons that trigger would get pulled.”

LaForte and Director of Clinical Operations Zendi Meharry said experience had shown that stong infection control protocols, including use of PPE and testing, can keep residents safe. 

“We will remain vigilant and we will continue, in the updated context, to do everything we can to ensure resident safety and quality of care,” LaForte said in an email to McKnight’s Long-Term Care News.

Summer break?

Warmer weather and its historically reduced risk of COVID transmission also makes this a potentially good time to pursue a change in policy, some providers said.

Holly Harmon, senior vice president of quality, regulatory & clinical services at the American Health Care Association/National Center for Assisted Living, said the move recognizes “the current stage of the pandemic and that requirements established throughout the course of the pandemic may no longer be prudent.”

“Furthermore, the COVID-19 vaccines have saved countless lives, and our focus will remain on encouraging the long term care community, especially our residents since they are most susceptible, to be up to date on their vaccinations. We appreciate the ongoing partnership of public health officials and other stakeholders to promote the importance of the vaccines.”

Bringing workers back to facilities

The mandate covers more than 10 million healthcare workers in the United States. Of those, CMS had estimated about 2.4 million were unvaccinated when it issued its interim final rule in late 2021.

The rule has been effective, even with its detractors. CMS data showed the nursing home staff vaccination rate at 62% nationally prior to the Administration’s announcement that it would pursue a mandate. That share had risen to 71% within three months, even without court approval or enforcement.

After being cleared by the Supreme Court, the mandate, along with allowed exemptions, pushed compliance rates close to 90%.

At least two major studies also revealed that vaccine requirements did not drive frontline staff from the sector, as many had feared.

A JAMA Health Forum study found that state COVID-19 vaccination mandates increased vaccinations among direct caregivers without negatively affecting staffing levels. Another published this January found the federal mandate did not significantly reduce staffing levels in nursing homes despite predicted “gloom and doom” scenarios by opponents.

“There’s no evidence that it was this big watershed event that impacted staffing levels inside nursing homes,” said co-author William F. Wempe, PhD, chair of the Accounting Department at Texas Christian University’s Neeley School of Business.

A boost to hiring prospects

But anecdotally, providers have told McKnight’s Long-Term Care News that it was a factor for some entry-level workers who could take alternative retail or other jobs without having to get vaccinated.

“Many applicants do ask about the vaccine requirement; indeed some choose not to accept a position within the nursing home because they prefer not to be vaccinated,” Stuart Almer, president and CEO of Gurwin Healthcare System in New York, told McKnight’s on Tuesday.

“In that way, lifting the mandate may help alleviate some staffing challenges,” he added. “As an organization, we will continue to educate staff and residents on the vaccine’s benefits, and continue to make vaccination convenient by stocking it in our in-house pharmacy.”

In states with more vaccine resistance among the general population, the lifting of the mandate could be more impactful, others said.

“In some of our states in the West, where there has been more measurable resistance to vaccines, this will probably start to create more opportunities in the labor pool, but we also have a few states with mandates, where that will continue to frame the issue for some workers,” LaForte said. “These areas are strong on choice and having their voice heard, but not always responsive to potential community burden,” LaForte added. [Removing the vaccine mandate is] probably not a huge needle mover with immediacy, but as things move on, we have some expectation that healthcare related jobs will start to become more attractive.”

Will states follow suit?

At the height of the pandemic, 25 states had adopted their own healthcare vaccine mandates; some allowed workers who didn’t get vaccinated to test more regularly as an alternative approach.

But some, including Massachusetts, have already announced that they would roll back their mandates in conjunction with the end of the national public health emergency on May 11.

Almer said that New York had recently deferred to CMS for some protocols such as visitor testing and masking.

“We anticipate this may also happen with the vaccine requirement as well,” he said.

While other nationwide vaccination requirements, such as those for federal workers, are being lifted in conjunction with the end of the public health emergency on May 11, no date was given for the healthcare rule’s end.

CMS bends

CMS on Monday had given a preview of its plan in new survey guidance, acknowledging that recent public health policy changes had influenced its approach to vaccination requirements.

“In light of these developments and comments received on the interim final rule, CMS will soon end the requirement that covered providers and suppliers establish policies and procedures for staff vaccination,” the agency said. “CMS will share more details regarding ending this requirement at the anticipated end of the public health emergency. We continue to remind everyone that the strongest protection from COVID-19 is the vaccine. Therefore, CMS urges everyone to stay up to date with your COVID-19 vaccine.”

When asked for additional details about the unwinding of the mandate, CMS Tuesday night repeated that language in a response to McKnight’s.

It is important to note that CMS is still standing behind other vaccination requirements, including reporting of resident shots to the NHSN system. That is “permanent and will continue indefinitely unless additional regulatory action is taken,” the agency notified surveyors.

Meanwhile, the requirement for all skilled nursing facilities to educate residents and staff on the COVID vaccine and additional doses and offer to help them get vaccinated will remain in effect until May 21, 2024.

LaForte noted that the civil monetary penalties attached to reporting and educational requirements still leave providers open to regulatory risk. Placing too little emphasis on vaccines after the mandate is lifted could do the same on the civil side too.

“The worry will be liability risk and the plaintiff’s bar, which, unfortunately, will likely leverage this as an opportunity to find fault with certain operators, notwithstanding the government opening up that liability with this change,” he said. “From a risk standpoint, a difficult piece to control is potential litigation, which worries us.”