Over 172,000 COVID deaths (more than one-third) are linked to nursing homes. It is clear that our health system needs to do more for America’s seniors. The good news is that scholars have done some deep thinking on how to reform the care delivered in nursing homes. These experts suggest: interagency governmental task forces, medical liability relief, workforce improvements and structural modernization. So, the ideas are out there, and Congress should just legislate, right?
It’s not that simple. There are a number of barriers Congress needs to work around in order to make progress.
The first barrier to comprehensive nursing home reform is split jurisdiction in the U.S. House of Representatives. The House Ways and Means Committee has jurisdiction over nursing home spending in the Medicare program. Often referred to as the “skilled nursing facility” benefit, Medicare provides services for short-term post-hospitalization needs. The House Energy and Commerce Committee has jurisdiction over nursing home spending in the Medicaid program. This “nursing facility” benefit provides services for long-term care. Together, Medicare and Medicaid constitute more than 50 percent of annual nursing home expenditures — meaning any reform will need to address the financing structure of both these entitlement programs.
Currently, W&M has 43 members and E&C has 58 members — meaning comprehensive bipartisan nursing home reform would need to be coordinated among 97 members of the House. Should committee leadership choose to pursue reform on a partisan basis, the House would still need support from 57 Democratic members — more than double the number of senators (28) needed for bipartisan support from the Senate Finance Committee. Should SFC decide to pursue reform on a partisan basis, support would be needed from only 14 senators.
Basic math suggests the Senate should take the lead in pursuing comprehensive nursing home reform. In addition, SFC has sole jurisdiction over both Medicare and Medicaid — the first barrier does not apply. However, the Senate has lagged behind the House in legislating nursing homes.
The second barrier to comprehensive nursing home reform is Senate hesitation to legislate. Over the past decade, there have been 16 bills signed into law with major health care policies. Among those bills, there were 9 discrete policies (56 percent) affecting nursing homes. Seven of those policies originated in the House — making the House 3.5 times more likely to legislate nursing homes than the Senate. As advocates for seniors, we all need to educate the Senate to make them aware of this discrepancy and urge the upper chamber to become more active. The Senate is ready to take on this challenge.
Within the last month, at least four members of SFC have publicly focused on nursing homes” Sen. Elizabeth Warren (D-Mass.) questioned executive compensation in light of COVID relief funds provided to nursing homes. Sen. Sherrod Brown (D-Ohio) raised concerns over private equity involvement in the management of for-profit nursing homes. Sen. Ron Wyden (D-Ore.) listed a number of grievances against the Trump Administration’s nursing home policies. And Sen. Mike Crapo (R-Idaho) referenced changes to Nursing Home Compare, many of which were suggested by SFC in 2019. These are all areas worthy of exploration and these individual Senate priorities should be added to the reforms included above to create a comprehensive bipartisan set of policies to improve care delivered in nursing homes.
Like baseball, legislating is a team sport. Teams from both the House and Senate must be interested in comprehensive nursing home reform. But, like baseball, only one team has home field advantage. Because of its sole jurisdiction over Medicare and Medicaid, the Senate has nursing home field advantage. Batter up!
Lisa Grabert is a research professor at Marquette University and a former congressional aide to the House Ways & Means Committee, where she had primary authorship over Medicare skilled nursing facility legislation.
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