Brad Anderson and Brent Willett

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From staff shortages to providing quality care, Iowa nursing homes face many challenges. We'll talk about the issues and what the industry and policymakers should do on this edition of Iowa Press.

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For decades, Iowa Press has brought you political leaders and newsmakers from across Iowa and beyond. Celebrating 50 years of broadcast excellence on statewide Iowa PBS, this is the Friday, July 7th edition of Iowa Press. Here is Kay Henderson.

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Henderson: Iowa nursing homes face workforce issues and their financial woes were a topic of debate in the Iowa legislature this past spring. Our two guests today are intimately familiar with the industry and are watching it closely. Brent Willett is with the Iowa Health Care Association. It is essentially the trade group for nursing homes, assisted living facilities and in-home care agencies. Brad Anderson is the State Director of AARP and represents retired persons and anyone who wants to join that organization. Gentlemen, welcome back to Iowa Press for this discussion today.

Thank you, Kay.

It's good to be here.

Henderson: Also joining the conversation, Katie Akin of the Des Moines Register and Erin Murphy of the Gazette in Cedar Rapids.

Murphy: Gentlemen, and Brent I'll start with you here, it has been kind of a transitional period, maybe is a soft way to say it, for the nursing home industry. A lot of closures in recent years. Has that continued in 2023? How many nursing homes have closed in Iowa this year?

Willett: We've seen a slowdown in closures in 2023. What I can say since 2020 really, the advent of the pandemic, we've lost 29 nursing homes in Iowa. The action of the Iowa legislature this session pertaining both in terms of a number of policy priorities that assisted facilities as well as appropriations has helped to slow that down. But we still have a long road ahead of us.

Murphy: And we're going to get to those, so it's good you bring that up. Are there others that are maybe teetering? Are there facilities out there that are on the brink and still in danger right now?

Willett: There absolutely are and it predominantly relates to the availability of qualified workforce. And certainly, the topic of debate for virtually any sector, any profession in Iowa, nursing facility level of care is no different. So, a number of rural nursing homes are really hanging on right now.

Murphy: And Brad Anderson, for the people that your organization represents and helps, what does this mean? And how critical an issue is this?

Anderson: It's absolutely critical and 40% of nursing homes in Iowa are currently experiencing a workforce shortage. So, that is double the national average. And one of the things we know is workforce shortages lead to poor quality of care and closures, as Brent mentioned. And s, we've seen a couple dozen closures over the last couple of years. One of the best ways to address the workforce shortage, at least in the short-term, is to increase the pay of direct care workers who are currently making on average about $15 to $16 an hour. So, if you're a single mom out there, which many direct care workers are, $15 to $16 an hour is not enough to get by. So, we need to increase the pay of direct care workers. Erin, I was going through some old files before this show and I came across this press release and the press release was from 1998 and it was AARP Iowa calling to increase the pay of direct care workers. And so, this yellowed press release, I was looking at it and it reminded me, the reason I'm bringing this up is because a lot of people frame this debate as a pandemic issue. And certainly, the pandemic exacerbated the workforce crisis in long-term care, there's no question about it. But it's not a pandemic issue. This is an issue that we have been dealing with in Iowa for decades. For decades we have been calling on the industry and the state and everyone to get together and find a way to increase the pay of direct care workers. And the reason we need to do it now more than ever is because of demand. And so, there is going to be an increase of about 17% in demand for long-term care over the next decade. As a percentage of population over 60, the percentage of population in Iowa over 60 is growing, the percentage of population under 60 is shrinking. Who is going to do this work? It's something we need to address and we need to address quickly.

Murphy: We've got all kinds of questions on that too. Katie has something on the legislation you mentioned.

Akin: Yeah, so just this year the Iowa legislature passed a $15 million increase in the Medicaid reimbursement rate at Iowa nursing homes. They also passed a bill that puts a year-long moratorium on new nursing home construction or the addition of new beds. Brad, starting with you, what do those changes mean for Iowa?

Anderson: Well, the funding I do think is important. We need to do two things in terms of the workforce. We need to stop the closure of nursing homes and address that issue. And we need to grow the home care industry and that workforce. So, the $15 million that you had mentioned for Medicaid is important. The thing that we would like to see is a little more transparency around how that money is being spent. And so, is that money being spent on the workforce? Is it being spent on direct care for the residents of the nursing homes? Or is it being spent on administration? Is it being spent on out-of-state investors? Right now in Iowa we don't have a way of seeing exactly how that money is spent. In other states they do. They require an appropriation, a certain percentage of it to be spent on direct care. At AARP we would like to see more transparency on how that money is spent. And it's not punitive, right, it's more instructive. We just want to see is it working? So, a year from now, we spent $15 million. Do we have more workers in the workforce? Is it being spent wisely? Or do we need to increase, decrease? What are the answers to all of those questions? Let's have some transparency.

Akin: And then Brent, what do you make of both that increase and the moratorium on new nursing home construction?

Willett: The increase is incredibly important. It will be met by a federal match because of the way the Medicaid program works for a total of about $42 million into the Iowa Medicaid system. And Brad's concern about transparency, we certainly have, place a high level of priority on ensuring that taxpayers understand where their Medicaid dollars are going. Iowa nursing homes, like any nursing home in the country virtually, submit what is a called a cost report to Iowa Medicaid. That is a publicly transparent document which documents exactly where those dollars are going. And what we know from those reports are that $7 out of every $10 spent in Iowa Medicaid money in nursing home care goes to workforce, goes to wages and benefits. And we certainly share the concern that Brad and his members share about increasing worker wages. What we've seen since that 2020 marker is that wages largely in Iowa nursing homes have increased by 32%, direct care workers, certified nurse aids specifically have increased by more than 36%. I think we used a number of $16. Brad, I think the most recent payroll-based journal numbers from the Centers for Medicare and Medicaid Services show in Q1 of '23 the average wage for a certified nurse aid was $21.13. So, we've certainly seen a major increase since that marker as well. Pertaining to the certificate of need moratorium, that is something, and you described it well, Katie, which will halt for a period of time the addition of new nursing home beds in Iowa. We think that is an important step. And the reason for that is that legislation calls for the Department of Health and Human Services to get together and update what is called the Nursing Facility Bed Need formula. That is a formula that determines, that is designed to determine where the need is for nursing facility beds in Iowa counties. And we fully support updating that formula. It has been many years since it has been updated. And ensuring that beds are going where they're needed and not where they're not across our state.

Henderson: How many, what percentage of Iowa nursing homes are for-profit versus not-for-profit?

Willett: We have more non-profit facilities in Iowa than for-profit facilities on a percentage basis.

Henderson: So, is it 60/40 maybe?

Willett: The specific number escapes me but I know that the majority are non-profit.

Henderson: When you look at this $15 million coupled with the moratorium, did legislators do that so nursing homes wouldn't use the extra money to add on a couple more beds or build a new facility?

Willett: I'm not sure those two debates were connected in that way. I think everybody -- look, we commend the Iowa legislature and Governor Reynolds and the Department of Health and Human Services for getting together and addressing an access to care issue that has been exacerbated by the pandemic. And so, the investment in Iowa Medicaid, which will be met by that federal match, is designed to address a devastating shortfall that was faced for providers, the distinction between the cost of administering care and the reimbursement for that care.

Henderson: Brad, does AARP have a number that you think would be adequate in terms of the reimbursement rate or the state's contribution to it?

Anderson: We don't have a number, what we have is a balance. So, right now for older Iowans the Medicaid balance is about 70% institutional care, 30% home-based care is where the funding is going. Of course, as you know, Kay, it's all about the money, right? And so, what we would like to see is more of a 50/50 split. And we've had conversations with Director Liz Matney, Director Kelly Garcia and they have been terrific and they understand that it's imbalanced and they're working on a plan. What I would offer is we need to completely transform and modernize the industry as a whole in the long-term. And let me share some numbers with you. We did a recent poll and we asked, where do you want to receive long-term care? 78% of Iowans who responded to the poll said, we want to receive that care at home. 12% said in assisted living. 4% said in a nursing home. So, home-based care is where Iowans want to receive that care. And if you look at the funding, the funding is, like I said, it's out of balance. And so, we need to address where people want to receive care and invest in where they want to receive that care, where they want to receive it is at home.

Henderson: Katie?

Akin: So, on the topic of in-home care, I'm curious if you could talk about the difference in wage between an in-home care worker and the wages for a worker in a nursing home facility? And as there is an increased demand for care in-home, how is that changing the industry overall? We can start with Brent.

Willett: Sure. So, we proudly represent hundreds of home health care agencies and home care agencies across the state at our association. So, we're intimately invested in ensuring that that sector is funded at an adequate level just like the rest of the long-term care system. Katie, you asked specifically about wages. The wage distinction between a home health care worker and a nursing home worker is depending on what specific job category you're looking for. But, we know there are a number of policy prescriptions that we can take today to increase the adequacy of payment and wages for home care workers. I'll give you one example. Currently, Iowa, like most states, does not reimburse, does not make reimbursement available for the travel time associated with a home health care aid. So, obviously a home care aid is moving from home to home. In rural Iowa sometimes those trips can be many, many miles, an hour or more. Currently, our system does not allow reimbursement for the travel time associated with that, which artificially holds down total wage levels. So, there's a number of policy prescriptions that we can take to increase that access to care. We believe absolutely, Brad, your numbers are of no surprise at all. We believe that nursing facility level of care should absolutely be the last resort. It is reserved for the most frail, elderly Iowans who cannot safely be cared for at home. We want everyone that can be safely cared for at home to receive that care. And we know that the workforce challenges associated with home care are further exacerbated by economies of scale. And so, it's certainly a place that we would like -- and I will, again, commend the legislature and Governor Reynolds for making permanent Medicaid rate increases for rural home care agencies and the HCBS elderly waiver system as a part of this last legislative session as well. Still work to do.

Henderson: What is the last part, HCBS?

Willett: HCBS, Home and Community Based Service elderly waivers. So, assisted living communities that provide Medicaid services, the rate that was increased temporarily with federal COVID dollars last year was made permanent by the legislature in its appropriations process this year.

Henderson: Thanks.

Murphy: There are some new federal requirements that are being discussed. Brent, we wanted to ask you about this, that would set the minimum standards for staffing levels at nursing homes. Again, it's kind of the balance, right, that's obviously something that nursing homes want, to have enough people to care for the residents. But we've talked about the workforce shortage. What are your thoughts on those requirements and how that will impact the industry?

Willett: You're right, Erin. Every single nursing home in Iowa would hire more staff if that staff were available. I think we can say that about virtually every profession or industry in our state. There's no question that there is a need for more staff. The question is what the instrument to actually make that happen is. A federal arbitrary mandate, which is what you're referencing, something that is proposed by the Biden administration, simply stated would require under penalty of ruinness fines, the mandated hiring of people who do not exist to care for people who do. And so, when our association looks at the proposal that is before the American people would require the hiring of more than 2,000 new direct care workers at a cost of more than $100 million. If those 2,000 people were available today, I can assure you that they would be hired immediately by Iowa nursing homes. So, the proposal shows a shocking lack of awareness about what is actually happening in rural health care by the Biden administration. Instead of creating an arbitrary mandate, we should be taking about real solutions to create more workforce to care for Iowa seniors. We should be taking about housing tax credits for direct care workers, child care assistance, telemedicine expansion. We should be talking about more investment in home and community-based services. Instead, we are going down the path of an arbitrary mandate which will not create another single worker, but simply penalize employers who are desperately seeking workers today.

Murphy: Brad Anderson, has the AARP considered this proposal?

Anderson: We have and we support the mandate. And I don't know how arbitrary it is only because my understanding of the mandate or regulation is that experts believe that is going to improve the quality of care. And in Iowa it's something that we need to do. So, let me start by saying, there are good actors out there any my mother-in-law recently went to a nursing home and she was treated wonderfully and I'm grateful for that. And so, I want to acknowledge that. But, we also have some serious challenges when it comes to quality of care and this new regulation is supposed to address those challenges. In Iowa, we've seen about a 45% increase in complaints to the Department of Inspections and Appeals, which investigates nursing homes. We've seen an increase in complaints to the long-term care ombudsman. I dare anybody to read the Iowa Capital Dispatch on a regular basis and you will be really concerned about what we're seeing in Iowa nursing homes today regarding abuse, neglect and various other issues. So, but we can talk about that and we should talk about that. But, what I'd like to talk about is really what does the future of long-term care look like and how do we address this quality issue? And it's an important issue. So, let me just paint a picture for you, Erin, real quick. And the picture is, say a community, as opposed to investing in a shiny new nursing home, they invest in home-based care and they find the workforce, they retrofit homes to allow older Iowans to age in place, which is where they want to be. And then, but we also know that we still need skilled nursing, right? So, they invest in a green home model. Now, a green home model, I don't know if you're familiar with this, it's where everybody gets their own room, there is a living room, there's a dining area, there is a community kitchen, maybe a fireplace and outdoor seating, but it's a smaller, more efficient nursing home. You have less staff turnover, fewer trips to the hospital and a better quality of care. So, now you've got home-based care, which is where people want to age, but if you need skilled nursing you've got a place where people would want to go. That model is the future of long-term care. It's going to take a long time for us to get there culturally in Iowa. That is where we want to be. Now, we have other states too, this green house model is not a fantasy, other states around us, Ohio, Minnesota, Missouri, Kansas, Illinois, they all have them. Iowa doesn't have a single green house. Why is that? It's because we need to change our thinking and approach to long-term care.

Murphy: We need to move on. But, Brent, I just wanted to give you a chance to respond to that. What about that idea? Is it kind of changing the way we look at the system holistically?

Willett: Yeah, I don't think this is a cultural issue at all. I think this is a funding issue. So, the green house model is something that we absolutely support in Iowa. We also recognize that on a per patient basis it's between five and eight times more expensive to care for an individual in a green house model. We absolutely want people to received that kind of elevated care, but we need to recognize that would require extraordinary new investment, which we would certainly support. But, we also need to, we need to recognize that we are operating in the system that we are. Certainly, an opportunity to pilot a green house system in our state is something we would support and expansion based on available resources is, again, something we would support.

Henderson: Katie?

Akin: Brad, you mentioned some of these unfortunate situations that have arisen at some Iowa nursing homes. The Department of Inspections and Appeals does fine these homes. But, some Iowans look at those fines and say, well that's not enough given what happened here. In terms of preventing situations from happening in Iowa nursing homes with inadequate care or negligence by staff, what needs to happen? And should those fines be higher? Brad, you can start us off, but I'll come to you, Brent.

Anderson: I don't know if the fines need to be higher. What needs to happen is workforce. I hate to sound like a broken record. But, when you have adequate staffing, you have fewer quality problems. And that is true across-the-board. And I think, Brent, you would agree with that. And so, we need to find a way to build up the workforce and that is a must. Now, when it comes to Iowans and what they should do about it, one of the things I would recommend is exactly what I did when my mother-in-law was trying to pick a nursing home to go to, just go on Medicare.gov Nursing Home Compare and see what gets the most stars. It's a five-star rating. We said, nothing below four stars essentially is what we were looking for. So, we looked in the Des Moines area and we found a nursing home that had five stars and she went there and received wonderful care. Unfortunately, we have a lot of one-star nursing homes. And if you click on the one star, you'll see that there's oftentimes a lack of workers, which is why it gets the one star. And so, not to oversimplify the issue, but if we don't solve the workforce crisis and start making that industry more appealing to the next generation, higher wages, improved working conditions, the ability to advance with the career, then we're going to have an enormous problem on our hands down the road because of the aging population.

Akin: And Brent, we have just a few minutes left. But, could you respond to whether those fines should be higher for some of these cases of negligence? And what can be done to make these nursing homes, prevent these situations from happening?

Willett: Look, there's really no evidence that expanding the level of fines improves the patient level of quality of care. Every single incident of sub-standard quality of care should be investigated and if that investigation proves to be founded, that provider should be penalized. We absolutely believe that. We also believe that, we also know that in 2022 Iowa nursing home providers provided about 7 million days of care. Of those 7 million days of care that resulted in about 2,112 incidents of inadequate care. It's less than half of one percent. Every single one of those 2,000 incidences of care should be investigated and if they were founded they should have been penalized. But, we also need to be careful not to suggest that the vast majority of the care that is being delivered by dedicated, hardworking Iowans every day is sub-standard. We have places to improve across our spectrum and I absolutely support what Brad said, using Nursing Home Compare, there is another measure on there that speaks to staffing levels in nursing homes.

Henderson: About a minute left, caregivers.

Murphy: Yeah, I apologize for sneaking this in at the end. So, as succinctly as you can in our last minute, one group we haven't talked about is there are some people who receive care just from their family in their home, they're not paid workers, it's literally the family taking care of their loved ones near the end of their life. Is there anything policy wise, Brent we'll start with you, that we can be doing to help those people?

Willett: Unpaid caregivers are incurring billions and billions and billions of unpaid hours of care every single year and we should absolutely recognize, understand, investigate, research how that care is being administered and develop federal solutions and funding to make that kind of care more feasible for families across the country.

Murphy: Brad?

Anderson: We have to do everything we can to support unpaid caregivers. We have 330,000 unpaid caregivers in the state of Iowa. One of the things, specific things that we support at AARP, Senator Joni Ernst introduced the Credit for Caring Act, which would give caregivers a $5,000 tax credit every year. At AARP we're strongly supportive of that. We would like to see eventually that bill passed.

Henderson: You both said federal solutions, is there anything at the state level that you support? Brad?

Anderson: Well, I support education at the state level. And, in fact, I was just having a conversation with someone here at the studio. If you have a question about caregiving, the best place to start, especially with older Iowans, is the Area Agency on Aging. Call your local AAA and they'll help you out.

Henderson: Gentlemen, to both of you, thanks for being on this edition of Iowa Press.

Thank you so much.

Thank you.

Henderson: You can watch every edition of Iowa Press online at iowapbs.org. For everyone here at Iowa PBS, thanks for watching.

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Funding for Iowa Press was provided by Friends, the Iowa PBS Foundation.

The Associated General Contractors of Iowa, the public's partner in building Iowa's highway, bridge and municipal utility infrastructure.

Elite Casino Resorts is rooted in Iowa. Elite's 1,600 employees are our company's greatest asset. A family run business, Elite supports volunteerism, encourages promotions from within, and shares profits with our employees.

Across Iowa, hundreds of neighborhood banks strive to serve their communities, provide jobs and help local businesses. Iowa Banks are proud to back the life you build. Learn more at iowabankers.com.