With Biden bowing out of a reelection rematch against former President Donald Trump and handing over the reins to Vice President Kamala Harris, his record on long-term care issues is all but complete.
The administration finalized most of Biden's policies through regulations, such as the staffing mandate and enhancements to the Special Focus Facilities program for the worst-performing skilled nursing homes, and other actions, including an executive order promoting caregiver workforce development.
Considering these and other efforts, Biden oversaw the most consequential period in nursing home regulation since President Ronald Reagan enacted the Nursing Home Reform Act of 1987, said David Grabowski, a health policy professor at Harvard Medical School.
Related: Biden health agenda winds down with big upcoming rules
Whether the Biden agenda will lead to lasting improvements in the nursing home industry remains to be seen, however, largely because its planks are all still so new, said Tamara Konetzka, a public health sciences professor at the University of Chicago and a member of the Medicare Payment Advisory Commission.
These policies, and the staffing rule in particular, also are under political pressure that could weaken or eliminate them. The American Health Care Association/National Center for Assisted Living and LeadingAge are suing to halt the workforce rule, as is the state of Texas. And some members of Congress — including a handful of Democrats — are trying to repeal the regulation.
And while Harris can be expected to continue the Biden administration's approach to long-term care if she wins, her campaign has not outlined any plans for the sector. Nor has Trump, but Republicans in general do not support the staffing minimums, at least.
Even if the policies survive the election, the courts and Congress, they aren't sweeping enough to transform the nursing home industry, Grabowski said. Moreover, the lack of additional funding for oversight and enforcement limits their impact.
Here's what the Biden administration attempted, and how its policies are playing out.
Safety and quality
The nursing home staffing rule, which mandates each resident receive at least 3.48 hours of nursing care per day including at least 0.55 hours from a registered nursing, is one of the most substantial changes to nursing home policy in decades, Grabowski said.
The nursing home industry characterizes the policy as unrealistic, citing nurse shortages, and too expensive, citing the lack of financial support for new hiring. CMS estimates nursing homes will spend $40 billion over 10 years to get staffing levels up.
“It's a little unclear whether or not the facilities really are going to find the money for this,” Konetzka said.
Long-term care groups paint a dire picture of what will happen if the rule isn't rescinded.
“Nursing homes will be forced to close their doors or limit admissions; hospitals will continue to be backed up with patients who can’t be discharged to nursing homes," a LeadingAge spokesperson wrote in an email. "Home health providers are already rejecting referrals and some face closure due to financial pressures and workforce shortages.”
The administration emphasizes that research has linked higher staffing levels to superior safety and quality.
Oversight and enforcement
CMS made efforts to more closely scrutinize what goes on inside nursing homes.
For instance, CMS empowered itself to target nursing homes that cycle on and off the Special Focus Facilities program without achieving sustained safety and quality improvements. The agency also enhanced its power to collect fines and ramped up audits to uncover cases of patients being inappropriately given antipsychotic drugs.
But neither the federal agency nor its state counterparts, which perform most inspections, received additional funding to enable greater oversight. For example, the budget for federal survey and certification activities has been flat at $397 million since fiscal 2015, according to CMS.
Transparency
The Biden administration introduced an unprecedented amount of transparency into the business of skilled nursing care when it mandated public disclosure of the individuals and companies that own nursing homes. This initiative called special attention to the relationship between private equity ownership and lower staffing levels, poorer safety and lower quality.
Workforce development
CMS issued a slew of policies meant to improve conditions for direct care workers, such as a making it easier for nursing home workers to unionize and issuing the executive order on the direct care workforce.
In conjunction with the CMS staffing rule, the Health Resources and Services Administration launched a $75 million campaign to support nursing careers.
Emergency preparedness
After witnessing the COVID-19 pandemic's effects on nursing home patients and staff, the administration took steps it contends will make the sector and the government better prepared for the next infectious disease outbreak.
For example, CMS:
- Finalized two vaccine data reporting measures tied to Medicare and Medicaid reimbursements.
- Continued COVID-19 testing.
- Continued COVID-19 vaccinations.
- Strengthened requirements for on-site infection prevention specialists.
- Improved protocols for pandemic and emergency preparedness.
