With only a month left in the legislative session, state leaders appear no closer to solving the unprecedented crisis facing Rhode Island’s nursing homes.
Bleeding cash and unable to hire enough qualified nurses and aides, the facilities – which provide care to the most vulnerable and frail Rhode Islanders – are being squeezed from all sides, according to nursing home administrators.
Industry leaders have been pushing for action by state officials to increase Medicaid reimbursement rates. The state-run Medicaid system underpays for resident care, covering only 65% to 75% of the actual cost per resident, nursing home operators say.
At the same time, nursing homes are bracing for massive fines by the state for failing to comply with a 2021 law that mandates minimum staffing ratios. The fines, which would have totaled $60 million in the first year, were temporarily halted by a now-expired executive order from Gov. Dan J. McKee.
McKee’s office says it's still determining the best way to proceed.
"At this time, the governor’s office is working with the General Assembly and other stakeholders to assess Rhode Island’s existing minimum staffing requirements and evaluate legislative solutions that support residents, workers, and the long-term health of facilities," said McKee spokeswoman Olivia DaRocha.
Senate spokesperson Greg Pare said the debate over Medicaid reimbursements is a "perpetual thing" that may be part of discussions about next fiscal year's state budget in the coming days and weeks. "Budget discussions are ongoing … I can’t speculate as to what components may or may not ultimately be approved," he said.
Larry Berman, spokesman for House Speaker K. Joseph Shekarchi, did not immediately return a message seeking comment.
Action in the General Assembly has so far been muted. While several pieces of legislation have been introduced to eliminate some of the minimum staffing fines and address some Medicaid concerns, none have made it out of committee as of June 1.
Senate Minority Leader Jessica de la Cruz, R-Burrillville, introduced a bill in May that would wipe out fines that would have been imposed through 2022. Under the staffing law, the overwhelming majority of nursing homes – 72% of them – would have been cited for noncompliance, said de la Cruz.
“The law is just unfair,” de la Cruz said. “It’s not about not wanting to comply. There simply aren’t enough [job] candidates.”
A companion bill has been introduced in the House. The measures have been referred to Health and Human Services Committees in each chamber.
Even if Rhode Island were to rescind the staffing law, the federal government is poised to enact a similar law mandating similar minimum staff ratios.
Meanwhile, the situation continues to take a toll. The owners of the 120-bed Charlesgate Nursing Center in Providence announced in May that it is closing, in part because of worker shortages.
The staffing problems for nursing homes are multifaceted.
It’s difficult to find employees to work for $16 to $19 an hour – the going rate for many of the non-nursing jobs, said operators and labor leaders.
To compound matters, the U.S. Department of State last month stopped issuing green cards to foreign-born nurses and certified nurse aides. Anyone who applied for an EB-3 visa after June 2022 is subject to the freeze. International medical workers, who can’t work in the U.S. without a visa, are a key component of staffing in Rhode Island.
“Nursing homes have been a perfect mess for years,” said Jesse Martin, executive vice president of the Service Employees International Union 1199 New England, which represents many nursing home workers.
“That’s because the industry has been neglected for a long time,” Martin said. “Why? Because it’s a program for poor people. And the vast majority of the workforce is female, Black or brown, and immigrants, and their work isn’t valued very much in our society. It’s only because profits are being threatened that you’re hearing about it now.”
Adding to the difficulties, newly graduated nurses are now being snapped up by hospitals offering $30,000 signing bonuses. Nursing homes can’t compete. In addition, the labor market for registered nurses and licensed practical nurses is extraordinarily tight following the wave of early retirements in part brought on by the exhaustion of caring for desperately ill patients during the pandemic.
The state’s nursing home industry isn’t holding out much hope.
“ ‘Perfect storm’ is such a cliche, but I don’t know what else to call it,” said John E. Gage, who represents 63 of the state’s 79 for-profit nursing homes as president of the Rhode Island Health Care Association.
“We’ve had six Rhode Island nursing homes close since the beginning of the COVID-19 pandemic,” Gage said. “If Medicaid funding doesn’t increase and the penalties start to be levied, we’ll have a disaster on our hands. You’ll see more of them close down, and hospitals will end up boarding patients who can’t go home.”
Medicaid pays nursing homes about $250 per patient, per day. The real cost is between $280 and $300, Gage said, “and that includes three square meals and staffing 24/7.”
Gage said he expects the General Assembly to increase Medicaid funding by 6.9% on Oct. 1. "But that still leaves us underfunded from years of cuts to the inflation index, skyrocketing expenses, and an unfunded staffing mandate," he said.
“We’re hopeful we’ll get another delay in penalties,” Gage added, “but that just kicks the can down the road.”
Richard Gamache is CEO of Aldersbridge Communities, a not-for-profit group that operates Linn Health & Rehabilitation in East Providence and three assisted living facilities.
“We’re losing our shirts in our nursing home,” said Gamache, who also teaches courses on long-term health care administration at Rhode Island College. “I have to use some of the revenue from our assisted living [facilities] to pay the staff at the nursing home.”
Federal pandemic money helped carry his facilities through the worst of the COVID-19 years, he said.
“The subsidies floated us. Now there are no subsidies. Every month we take a huge loss,” Gamache said. “We have the greatest staff in the world. What am I going to do, not pay them?”
As a not-for-profit, Gamache said, Aldersbridge has no shareholders or owners to pay. “If we make money, it goes into salaries, the utilities, and food, and liability insurance. Those costs have all gone up,” he said.
Gamache believes the entire long-term health care system needs an overhaul. Many of the solutions he said are outlined in a report issued last year, The National Imperative to Improve Nursing Home Quality, completed by the National Academies of Sciences, Engineering, and Medicine.
Among the 600-page report’s many recommendations: increased funding, minimum staffing requirements, and adequately compensated employees.
“I’m not sure where bottoming out is. I think we’re already there,” Gamache said. “What will it take to have things change in Rhode Island? Will three or five more places in the state have to close?
“Can we really afford to wait? Something has to be done now.”
(Update clarifies in the 24th paragraph the Medicaid funding increase that Gage is expecting during this legislative session.)
