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Double Jeopardy: The Pandemic and longstanding Privatization of US Long-Term Care


By: LaTonya J. Trotter

Residents of long-term care facilities account for less than 1% of the US population. Yet, by December of 2020, they accounted for close to 40% of all coronavirus deaths. Residents of these facilities are particularly vulnerable to the virus.  Not only because of their age or health, but because transmission is difficult to avoid when living under the same roof. Yet, neither congregate living conditions nor medical frailty alone fully explain this increased vulnerability. The preexisting problems of underfunding and understaffing in long term care are key—and preventable—drivers of this deadly trend.

That long-term care in the US is woefully under-resourced is no secret. While financial planners advise individuals to “save, save, save,” for retirement, it only takes a few years of out-of-pocket medical and supportive care costs to decimate the savings of even the most careful planner. As a result, Medicaid—the program that pays for the health care of those who fall beneath the poverty line—funds upwards of 60% of long-term care costs in the US. However, Medicaid has never been funded well enough to entirely meet this demand. Standard government reimbursements only cover 70-80% of the actual cost of care. Dealing with chronic underfunding is a challenge during the best of times. During the pandemic, it has proven to be a literal death sentence for many.

The increased cost of personal protective equipment (PPE) and testing have strained the budgets of facilities that were already dealing with chronic underfunding. Without a coordinated federal system, each facility has largely had to fend for itself, both in terms of finding resources like PPE, but also in terms of financing them. Almost a year into the pandemic, nursing homes continue to report shortages of PPE, leaving staff to deal with substandard and ineffective equipment not certified for medical use, or to attempt to reuse single-use PPE.

The increased risk of infection for direct care staff has only exacerbated the difficulty of staffing long term care. The certified nursing assistants who provide much of the direct care in nursing homes were already in short supply because of their low wages and difficult working conditions. When facilities are unable to find or afford adequate PPE for all its staff, the risk of covid-19 infection, illness, and mortality not only goes up for residents, but for the people who care for them.

The pandemic has not only strained the supply of available workers, but also the demands made on those who are able to continue to work. Direct care workers have seen their patient load increased, been asked to bear most of the burdens of increased infection control measures, and in some facilities, and to take on new forms of work such as handling the bodies of the dead for overburdened funeral homes. Moreover, with facilities closed to visitors, it is the workers left behind who feel the pressure to provide the practical and emotional support that would normally be provided by family members, friends, and community volunteers.

The pandemic has made life harder for both staff and residents of long-term care. But it did not create the longstanding challenges caused by chronic underfunding and the systematic devaluing of direct care workers. If the care of dependent populations was prioritized over profits, the pandemic may have been less of a tragedy not only for the residents of long-term care facilities, but for the people that care for them.

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