As California Gov. Gray Davis decides whether to sign a bill requiring nursing home operators to hire more staff, he's getting pressure from all sides.
Not surprisingly, organized labor and consumer groups such as the American Association of Retired Persons are urging him to sign the measure. But support for the bill also comes from a more unusual corner: the nursing home industry.
Pinched by tight budgets and an even tighter labor market, some in the nursing home industry are setting aside their dislike of staffing mandates in return for a fiscal shot in the arm.
"We're supportive of the increased staffing because (the bill) also provides for the funding," said Kelley Queel, spokeswoman for the California Association of Health Facilities.
The Sacramento-based nursing home group initially opposed the bill, she said, but changed its tune when the state promised $36 million.
Davis has until Oct. 11 to sign the bill.
The measure represents a compromise between labor and industry.
"We recognize that climbing that hill (to higher staffing ratios) is a high hill to climb," said Beth Cappell, a Sacramento-based healthcare advocate for the Service Employees International Union, which supports the Medicaid rate increases because they are tied to staffing.
The CAHF also supports the bill because it requires the state Department of Health to develop a Medicaid payment system that would reflect patient acuity. California is one of only four states where Medicaid pays nursing homes a flat per-resident rate regardless of patients' medical needs.
Nursing home operators have historically lobbied hard against legislation imposing or increasing minimum ratios of staff to residents or minimum nursing hours per patient.
Federal law already requires nursing homes to staff appropriately, they argue. Regular inspections ensure that nursing homes provide adequate care, so mandating specific staffing ratios is redundant, the argument goes.
"Staffing needs should be based on the patients' care needs, not on an arbitrary level," said Robert Murphy, legislative director for the New York State Health Facilities Association, which opposes staffing mandates.
When bills have tied staffing requirements or wage increases to better reimbursement, however, the industry has largely supported them and has even worked with their counterparts in labor unions to get such legislation passed.
The Arkansas association for for-profit nursing homes worked for passage of a bill this year that allocates more Medicaid dollars in return for new staffing ratios.
In Wisconsin, as result of meetings between industry and organized labor, the current budget bill includes wage increases for nursing home staff. The measure is under debate.
A similar coalition in Minnesota pushed through a significant wage increase two years ago and this year succeeded in gaining passage of a smaller increase.
But industry opposition has largely killed bills that mandated staffing increases without providing extra funding.
Bob Angelo, legislative director for the SEIU in New Jersey, where a bill to establish staffing ratios has all but stalled, said, "Industry wasn't as opposed to the concept as it is to the cost."
Rick Abrams, president of the New Jersey Association of Health Care Facilities, said that more than money is at stake.
"Nursing homes are having tremendous difficulty hiring and keeping staff," he said.
Exacerbating the effects of the labor crunch is the negative public perception of nursing homes, those in the industry said.
"Any time you have a profession that's so maligned, it's difficult to recruit," said Jane Johnson, director of housing for the Florida Association of Homes for the Aging. Johnson said she knew of facilities that have offering sign-up bonuses of up to $1,500 for certified nursing assistants but have had no responses.
Florida's Legislature allocated $32 million in new funding to nursing homes for hiring and retaining staff.
Johnson called that a positive step but cautioned it might not be enough. But Dale Ewart, deputy director of Unite for Dignity, a joint project between the New York-based Union of Needle Trades Industrial and Textile Employees and the SEIU in South Florida, said the industry helped create the staffing crunch and high turnover. "As long as nursing home operators view (certified nursing assistant) jobs as disposable, low-wage no-benefit jobs, of course (they'll have high turnover)," he said.
"We still believe very strongly that nursing home ratios need to be brought up to date."