It’s a time to worry, a time to mourn, but also a time to learn.
A staggering 80 percent of COVID-19 deaths are occurring among senior citizens 65 years and older. Today, seniors make up 16 percent of the total population, a percentage bound to increase in the future.
The overwhelming majority of seniors are U.S. citizens, mostly born here, whereas the naturalized U.S. citizen population is on average much younger. Long-term care facilities and nursing homes housing senior citizens are the eye of the storm.
Over 4,800 people have now died from COVID-19 in New York’s nursing homes, including 1,050 on Long Island. The high risk of infection in long-term care facilities is not a new phenomenon and will most likely persist after this pandemic slows down, whenever this might happen. A large number of fatalities have occurred among health care workers and other staff employed by operators of residential facilities.
Chronic understaffing and scarcity and misuse of personal protective equipment are contributing factors in long-term care facilities’ high rates of infection among patients and workers. Learning how to better protect seniors in the future starts with learning how to improve the working conditions and overall protection of health care workers.
About 1.5 million seniors are housed in long-term care facilities. The largest number of seniors by far live in family households or by themselves. Their deaths are less visible, even if much larger in number. In New York State, over two-thirds of COVID-19 newly hospitalized patients were reported living in their homes.
What we learn from the pandemic in residential facilities is also relevant to the entire at-risk senior population. A major issue, seldom addressed in the media before the pandemic, is the safety and protection of the members of the health care workforce who are taking daily care of seniors everywhere and are essential to their protection.
We are now learning how ill-prepared these facilities were for a pandemic. Inspections regularly conducted in the past by the Centers for Medicare and Medicaid Services, or CMS, of licensed facilities, including the highest-ranked, found numerous failures in infection control in about 60 percent of the cases, but improvements might not have followed inspections.
CMS actually set in motion last July a plan to weaken rules requiring nursing homes to employ at least one specialist in preventing infections. Efforts at the federal, state and local levels since late March came too late to prevent the daily increase in fatalities, because chronic understaffing has most likely increased, testing is still not universally available, scarcity of PPE is still a challenge, as indicated by Centers for Disease Control and Prevention guidelines for long-term care facilities issued as recently as April 30, and systemic failures in health care cannot be fixed on short notice.
CMS guidelines for group residences issued for influenza and other contagious diseases many years ago underline the importance of rapid identification of cases, prompt treatment, and isolation to prevent transmission.
Restricting admissions or visitors, and keeping infected staff out of work, are major recommendations. Most facilities in the country have barred visitors only since mid-March, even though alarm bells were sounding much earlier. They are still largely unable to safely control COVID-19 infections and their in-house transmission.
How is the virus introduced into the facilities? Non-resident staff shows up for work unchecked every day, unless self-reporting as sick, and dissemination within the facilities is not properly controlled, since PPE is not widely available.
Operators of long-term care facilities are large-scale employers of nurses, assistant nurses and direct care workers carrying out the daily routines of feeding, cleaning and caring for the resident population. Nursing assistants, home health aides, personal care aides and psychiatric assistants comprise over 70 percent of the workforce they employ.
In 2015, there was an estimated demand for approximately 2.3 million direct care workers, according to the U.S. Department of Health and Human Services, about half of them in home- and community-based settings, the other half in residential care facilities and nursing homes.
Direct care workers are predominantly women with a multi-racial and immigrant backgrounds. The majority have a high school or some college education, and about half of them hold part-time jobs with more than one employer, earn a median annual income of slightly over $20,000, and live in middle-to-low income neighborhoods where the incidence of COVID-19 is higher.
In states such as New York and New Jersey, over 40 percent of direct care workers are immigrants from Latin America, the Caribbean and Asia.
Jobs requiring training and skills for direct work, accessible through short-term certification that is seldom a requisite for employment, could not be covered at current wages without a steady supply of female immigrant workers. Many states have faced the challenges of finding and retaining long-term service direct care workers by raising salaries and through workforce development strategies, according to the Kaiser Family Foundation.
The anti-immigrant environment often faced by immigrant communities, which includes citizens, permanent residents, work permit holders and undocumented individuals, poses a major barrier to these recruiting efforts.
Universal testing for COVID-19 of health care personnel and generous paid leave arrangements for quarantine in all positive cases is urgently needed, as is the universal testing and provision of PPE, with appropriate enforcement rules.
Medicaid and its state-level partners, already covering 62 percent of nursing home residents, should be responsible for financing and implementing testing and PPE rules among all licensed providers. The additional burden on health budgets should be taken care of by legislation meant to address shortfalls caused by the COVID-19 pandemic.
The health care industry as a whole is now suffering a historic collapse in business. Health care spending declined 18 percent during the first quarter of 2020, and a worse decline is expected for the current quarter. Hospitals and health care systems all over the country are reported in recent weeks as having to furlough part of their workforce, contributing to the millions filing unemployment claims since mid-March. Prospects for future employment in this sector will be dimmed by the expected decline in state revenues, leading to severe cuts in health budgets.
Many immigrant workers are not eligible for unemployment benefits or are afraid of filing for unemployment and other government benefits. Furthermore, many immigrants and their U.S.-born spouses and children are disqualified from receiving federal cash assistance under the CARES Act of late March when they lack a Social Security number. This exclusion is despite the fact that, according to the IRS, 4.35 million people in 2015 — including undocumented immigrants, their U.S.-citizen spouses and children — paid over $13.7 billion in net taxes using an individual taxpayer number.
The recent announcement of a 60-day immigration ban, although quite limited in scope, has stoked further fear within immigrant communities in the United States who are already suffering the effects of the pandemic upon the health and economic well-being of their families.
These front-line health care workers are unlikely to be replaced by robots anytime soon.
The number of U.S. citizens 65 years of age and older eligible for Medicare and Medicaid is bound to increase. Person-to-person transmissible diseases will not be entirely controlled through vaccination, and alerts will not be effective in preventing other pandemics, unless there is equipment and trained personnel already in place to cover the growing demands of the senior population.
We cannot properly protect our seniors, whether in residential facilities or at home, without also protecting the jobs, safety and economic well-being of all health care workers — including immigrants, regardless of their immigration status — who provide daily professional, semi-professional and direct care for seniors now and who will do so well into the future.
A first crucial step in the right direction would be the inclusion of immigrants within the provisions of the CARES Act.
A resident of Westhampton, Jorge Balán is a sociologist with decades of research and teaching experience. Before retirement, he was as an adjunct research scholar and professor at the School of International and Public Affairs at Columbia University.
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