vox--2020-07-14--Money Talks: The couple navigating child care in the pandemic

Welcome to Money Talks , a series in which we interview people about their relationship with money , their relationship with each other , and how those relationships inform one another .
Evan is a 33-year-old blogger and parenting writer at Dad Fixes Everything .
His wife , Sarah , is 31 and is the director of customer strategy and success at a software company .
They live in Atlanta , and their annual household income is around $ 200,000 .
Evan and Sarah have a 5-year-old daughter and a new baby due in August .
Prior to the coronavirus @ @ @ @ @ @ @ care and spent some afternoons with her grandparents .
Now Evan and Sarah are trying to balance work , child care , and public health concerns as they navigate an unpredictable summer .
As coronavirus cases rise in Georgia , Evan and Sarah have to decide whether they should still send their daughter to day camp next week — and whether they ’ re going to let her attend kindergarten when schools reopen this fall .
Sarah : Georgia is great because it has a state-funded pre-K program , so [ prior to @ @ @ @ @ @ @ pre-K day care from 8 am to 2:15 pm every day .
Then we did a combination of after-school activities , Evan doing some afternoon care because his job is flexible , and the grandmas each taking one afternoon .
Evan : The state pre-K was free but held at the same private day care we used when our daughter was younger .
We paid about $ 200 per month for her meals , snacks , and other costs there while in pre-K. Sarah : Then her school suddenly closed — it was @ @ @ @ @ @ @ everything started happening — and at that point , we went from school plus grandparents and flexible things to just the two of us working from home and taking care of her full time .
Evan : It was going to be an unusual summer for us anyway , because our daughter was transitioning out of day care .
We had signed her up for some day camps and some week-long camps , hoping to get a little bit of coverage while we were both trying to work over the summer , and @ @ @ @ @ @ @ that into uncertainty .
Sarah : Georgia ’ s schools get out really early , so most of the summer camps started at the end of May .
Some of the ones that we had signed her up for didn ’ t go through , like this art camp she was going to be in .
She did attend one week-long camp back in the beginning of June ; it was a swim camp where they had swim lessons twice a day .
She wasn ’ t swimming yet , so we were @ @ @ @ @ @ @ versus exposure to the virus ?
” We did end up sending her , and they followed all of the state regulations .
Frequent cleaning , no sharing food — Evan : Temperature checks at the door , all of that kind of stuff .
Sarah : That went really well , so that gave us a little more confidence .
Then , of course , cases started rising , so we ’ re starting to get a little more uneasy .
Next week she is supposed to attend her second camp , @ @ @ @ @ @ @ pending what happens over the next week in the state , with some of the cases — we ’ re still planning on sending her , right now .
Evan : We ’ re always reevaluating , depending on what ’ s happening , and the camps are doing that too .
They won ’ t really say anything until a couple weeks before things are scheduled to start , and then they ’ ll make the best call they can .
You ’ re never really quite sure what ’ s going @ @ @ @ @ @ @ re constantly weighing the risks of exposure and all of that — and I ’ m pregnant , so that ’ s a whole other complexity in there .
But you can tell , when our daughter hasn ’ t done something for a while , you can see her mood changing .
Leading up to the swim camp , we had a pretty rough week .
Then we went to swim camp , and then we had a week where we went to the beach and rented a condo and were isolated @ @ @ @ @ @ @ of pace .
The two weeks after that were great , and now you can see her starting to get really bored of us again .
Evan : Even though the camps are expensive and they make us a little nervous , it ’ s nice to see our daughter get excited about something .
Without camps , we ’ d be stuck continuing to “ trade off ” parenting duty throughout the day so each of us could work .
It ’ s tough because Sarah has easily 40-plus hours of work @ @ @ @ @ @ @ a handful of productive hours each day to do it .
I run my own business and have a lot of flexibility , but it ’ s been a real struggle to continue growing it without much time to spend .
Sarah : Most of the camps she ’ s in are about $ 250 to $ 350 a week , depending on the camp .
They were all prepaid , but anything that we paid could be put toward a camp next year [ if we decided not to attend ] .
@ @ @ @ @ @ @ put the money toward swimming lessons , and the other one said you could put it toward next year ’ s tuition .
Evan : We initially signed up for over $ 1,000 in summer camp costs .
These are camps where we drop her off and we ’ re trusting she ’ s in the care of the camp for the whole day , and then we get to go home and try to focus on our work for a few hours .
Sarah : Actually , because of Covid , the @ @ @ @ @ @ @ ’ t even walk her in or anything .
Someone comes and gets her from our car , does the temperature check , and takes her in .
Evan : Pulling up the first day , dropping her off with people we ’ d never met , not going in and getting her settled — that ’ s the way they ’ re doing it now .
I just worry that we ’ re surging ahead with opening everything up , regardless of whether it ’ s safe .
We ’ re doing @ @ @ @ @ @ @ , but I worry that it ’ s not enough .
Sarah : Kids and masks , how much can they really enforce kids wearing them ?
I feel like we have to knowingly take the risk without counting on that protection .
Evan : Our daughter actually kind of likes her mask .
She thinks it ’ s exciting .
We got her a special one with a unicorn on it , and she wants to wear it .
She ’ s not dreading that she has to put it on every @ @ @ @ @ @ @ the understatement of the century .
Evan : My mom , it ’ s safe to say , is in the compromised population .
She has some health problems , and we don ’ t really want to expose her .
She ’ s really locked down , so I ’ m really cautious to bring anything her way .
Sarah ’ s mom works in a health care setting and has been working with Covid patients , so we ’ re worried about being exposed to what she might be bringing home @ @ @ @ @ @ @ of conversations about the level of risk that we ’ re comfortable with , so we can see our family .
Sarah : During the first 10 weeks , we were like , “ They can come to the driveway and have a socially distanced chat , and that ’ s it.
” Then , like a lot of other people , we ’ ve gotten worn down somewhat — so we started to reintroduce seeing them .
With my mom , she works two nights a week and they ’ re back @ @ @ @ @ @ @ see her after she ’ s had a few days of not being at work .
She ’ s a hospice nurse , and they have had a handful of Covid patients .
With Evan ’ s mom , she ’ s been fine with seeing our daughter right now , but when our daughter goes back to school , we ’ re going to worry about that as well .
Evan : We live in a neighborhood where there are a lot of kids , and the kids run around outside all @ @ @ @ @ @ @ whatever they want to do without supervision .
Sarah and I are not really comfortable with our daughter being outside with other kids , unsupervised and sharing germs , but we go back and forth sometimes .
She misses her friends , and she looks out the window and sees them playing — we ’ ve had some disagreements about it , and we ’ ve had to weigh the pros and cons a lot .
The emotional health of our child versus keeping her safe .
Sarah : I think , like @ @ @ @ @ @ @ we were on opposite sides of it , but then we talked it through and got to a good conclusion together .
Evan : Here ’ s what we ’ re in the middle of right now .
Our school district decided to punt the decision to parents : “ We ’ re going to start on time .
You can keep your kids at home for the semester , or you can send them.
” Sarah : Georgia schools start a little earlier than the rest of the country , so August @ @ @ @ @ @ @ we decide to send her .
Two weeks before my due date .
Evan : We have to decide within the next week , honestly , whether we ’ d like to send her to school and expose ourselves to whatever that may bring , before we ’ re about to go into delivery , or whether we want to keep her home for the semester and deal with a new baby at home while doing virtual learning .
We ’ re really struggling with this decision at this point .
Sarah : @ @ @ @ @ @ @ leave , so I ’ ll be off until the middle of November .
Evan works for himself , so he has flexibility — but he still has to run his business .
Our daughter hasn ’ t had any virtual learning yet , so that ’ s another thing .
Evan : I would say she doesn ’ t love video chat .
It ’ s hard for her to sit down and watch a screen and have a normal , structured conversation .
When we visit the grandparents on video , @ @ @ @ @ @ @ on the silly filters and shows them everything in the house .
Sarah : The only time she has a tablet is if we ’ re going on a long car ride or plane ride .
She usually watches something then .
She hasn ’ t done a lot of computer games or online activities or anything like that , so I don ’ t know how that would go .
Evan : I don ’ t know where the tipping point is .
It feels like the cases are going to go @ @ @ @ @ @ @ going to explode to the point where it will be obvious that we shouldn ’ t send her .
Sarah : I don ’ t know — they are going up quite a bit !
Evan : It doesn ’ t feel like they ’ re going to go down and we ’ re going to be able to say , “ Everything ’ s safe now.
” Sarah : She ’ s a super-bright little girl and we really want her to be in a school setting , so I feel like @ @ @ @ @ @ @ school will happen a lot sooner , just because of the pros of it , versus some of the other things , like large gatherings or anything like that .
I don ’ t know when I would feel comfortable with a large group gathering .
Probably a long time from now .
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Welcome to Money Talks, a series in which we interview people about their relationship with money, their relationship with each other, and how those relationships inform one another.
Evan is a 33-year-old blogger and parenting writer at Dad Fixes Everything. His wife, Sarah, is 31 and is the director of customer strategy and success at a software company. They live in Atlanta, and their annual household income is around $200,000.
Evan and Sarah have a 5-year-old daughter and a new baby due in August. Prior to the coronavirus pandemic, their daughter went to day care and spent some afternoons with her grandparents. Now Evan and Sarah are trying to balance work, child care, and public health concerns as they navigate an unpredictable summer. As coronavirus cases rise in Georgia, Evan and Sarah have to decide whether they should still send their daughter to day camp next week — and whether they’re going to let her attend kindergarten when schools reopen this fall.
Sarah: Georgia is great because it has a state-funded pre-K program, so [prior to the pandemic] our daughter was in pre-K day care from 8 am to 2:15 pm every day. Then we did a combination of after-school activities, Evan doing some afternoon care because his job is flexible, and the grandmas each taking one afternoon.
Evan: The state pre-K was free but held at the same private day care we used when our daughter was younger. We paid about $200 per month for her meals, snacks, and other costs there while in pre-K.
Sarah: Then her school suddenly closed — it was that Friday [March 13] when everything started happening — and at that point, we went from school plus grandparents and flexible things to just the two of us working from home and taking care of her full time.
Evan: It was going to be an unusual summer for us anyway, because our daughter was transitioning out of day care. We had signed her up for some day camps and some week-long camps, hoping to get a little bit of coverage while we were both trying to work over the summer, and the coronavirus lockdown threw a lot of that into uncertainty.
Sarah: Georgia’s schools get out really early, so most of the summer camps started at the end of May. Some of the ones that we had signed her up for didn’t go through, like this art camp she was going to be in. She did attend one week-long camp back in the beginning of June; it was a swim camp where they had swim lessons twice a day. She wasn’t swimming yet, so we were like “Do we weigh water safety versus exposure to the virus?” We did end up sending her, and they followed all of the state regulations. Frequent cleaning, no sharing food —
Evan: Temperature checks at the door, all of that kind of stuff.
Sarah: That went really well, so that gave us a little more confidence. Then, of course, cases started rising, so we’re starting to get a little more uneasy. Next week she is supposed to attend her second camp, and we are currently still thinking — pending what happens over the next week in the state, with some of the cases — we’re still planning on sending her, right now.
Evan: We’re always reevaluating, depending on what’s happening, and the camps are doing that too. They won’t really say anything until a couple weeks before things are scheduled to start, and then they’ll make the best call they can. You’re never really quite sure what’s going to happen.
Sarah: We’re constantly weighing the risks of exposure and all of that — and I’m pregnant, so that’s a whole other complexity in there. But you can tell, when our daughter hasn’t done something for a while, you can see her mood changing. Leading up to the swim camp, we had a pretty rough week. Then we went to swim camp, and then we had a week where we went to the beach and rented a condo and were isolated there, and it was a change of pace. The two weeks after that were great, and now you can see her starting to get really bored of us again.
Evan: Even though the camps are expensive and they make us a little nervous, it’s nice to see our daughter get excited about something. Without camps, we’d be stuck continuing to “trade off” parenting duty throughout the day so each of us could work. It’s tough because Sarah has easily 40-plus hours of work to get done each week and only a handful of productive hours each day to do it. I run my own business and have a lot of flexibility, but it’s been a real struggle to continue growing it without much time to spend.
Sarah: Most of the camps she’s in are about $250 to $350 a week, depending on the camp. They were all prepaid, but anything that we paid could be put toward a camp next year [if we decided not to attend]. One swim camp would have let you put the money toward swimming lessons, and the other one said you could put it toward next year’s tuition.
Evan: We initially signed up for over $1,000 in summer camp costs. These are camps where we drop her off and we’re trusting she’s in the care of the camp for the whole day, and then we get to go home and try to focus on our work for a few hours.
Sarah: Actually, because of Covid, the policies have been stricter. We can’t even walk her in or anything. Someone comes and gets her from our car, does the temperature check, and takes her in.
Evan: Pulling up the first day, dropping her off with people we’d never met, not going in and getting her settled — that’s the way they’re doing it now. I just worry that we’re surging ahead with opening everything up, regardless of whether it’s safe. We’re doing the temperature checks and the hand sanitizing, but I worry that it’s not enough.
Sarah: Kids and masks, how much can they really enforce kids wearing them? I feel like we have to knowingly take the risk without counting on that protection.
Evan: Our daughter actually kind of likes her mask. She thinks it’s exciting. We got her a special one with a unicorn on it, and she wants to wear it. She’s not dreading that she has to put it on every day.
Sarah: That’s definitely true.
Evan: [Visiting the grandparents]… well, it’s complicated.
Sarah: That’s the understatement of the century.
Evan: My mom, it’s safe to say, is in the compromised population. She has some health problems, and we don’t really want to expose her. She’s really locked down, so I’m really cautious to bring anything her way. Sarah’s mom works in a health care setting and has been working with Covid patients, so we’re worried about being exposed to what she might be bringing home. We’ve had a lot of conversations about the level of risk that we’re comfortable with, so we can see our family.
Sarah: During the first 10 weeks, we were like, “They can come to the driveway and have a socially distanced chat, and that’s it.” Then, like a lot of other people, we’ve gotten worn down somewhat — so we started to reintroduce seeing them. With my mom, she works two nights a week and they’re back to back, so we’ll see her after she’s had a few days of not being at work. She’s a hospice nurse, and they have had a handful of Covid patients. With Evan’s mom, she’s been fine with seeing our daughter right now, but when our daughter goes back to school, we’re going to worry about that as well.
Evan: We live in a neighborhood where there are a lot of kids, and the kids run around outside all day together, climb trees, do whatever they want to do without supervision. Sarah and I are not really comfortable with our daughter being outside with other kids, unsupervised and sharing germs, but we go back and forth sometimes. She misses her friends, and she looks out the window and sees them playing — we’ve had some disagreements about it, and we’ve had to weigh the pros and cons a lot. The emotional health of our child versus keeping her safe.
Sarah: I think, like with seeing my mom at first, we were on opposite sides of it, but then we talked it through and got to a good conclusion together.
Evan: Here’s what we’re in the middle of right now. Our school district decided to punt the decision to parents: “We’re going to start on time. You can keep your kids at home for the semester, or you can send them.”
Sarah: Georgia schools start a little earlier than the rest of the country, so August 3 is her first day, if we decide to send her. Two weeks before my due date.
Evan: We have to decide within the next week, honestly, whether we’d like to send her to school and expose ourselves to whatever that may bring, before we’re about to go into delivery, or whether we want to keep her home for the semester and deal with a new baby at home while doing virtual learning. We’re really struggling with this decision at this point.
Sarah: I have 12 weeks of paid maternity leave, so I’ll be off until the middle of November. Evan works for himself, so he has flexibility — but he still has to run his business. Our daughter hasn’t had any virtual learning yet, so that’s another thing.
Evan: I would say she doesn’t love video chat. It’s hard for her to sit down and watch a screen and have a normal, structured conversation. When we visit the grandparents on video, she runs around the house and puts on the silly filters and shows them everything in the house.
Sarah: The only time she has a tablet is if we’re going on a long car ride or plane ride. She usually watches something then. She hasn’t done a lot of computer games or online activities or anything like that, so I don’t know how that would go.
Evan: I don’t know where the tipping point is. It feels like the cases are going to go up, but they aren’t going to explode to the point where it will be obvious that we shouldn’t send her.
Sarah: I don’t know — they are going up quite a bit!
Evan: It doesn’t feel like they’re going to go down and we’re going to be able to say, “Everything’s safe now.”
Sarah: She’s a super-bright little girl and we really want her to be in a school setting, so I feel like our comfort level with sending her to school will happen a lot sooner, just because of the pros of it, versus some of the other things, like large gatherings or anything like that. I don’t know when I would feel comfortable with a large group gathering. Probably a long time from now.
If you have a compelling story about how money comes into play in one of your relationships — whether with a partner, a friend, a sibling, a coworker — we want to hear about it! Email alanna.okun@vox.com and karen.turner@vox.com with a little about yourself.


vox--2020-07-14--Trump reduced fines for nursing homes that put residents at risk. Then Covid-19 happened.

Few places represent the calamity of the Covid-19 pandemic as well as the Life Care Center of Kirkland .
Starting in February and escalating into early March , the nursing home in a Seattle suburb became one of the disease ’ s first hot spots in the United States .
By March 9 , more than a week before any state had issued a stay-at-home order , the Kirkland facility already had 129 cases ( 81 among residents ; the rest among staff and visitors ) and 23 deaths from the novel coronavirus , according to a Centers for Disease @ @ @ @ @ @ @ , it became clear that practices at the Kirkland facility contributed to the spread of the virus there , according to federal inspectors .
A Washington Post investigation found that the problems were endemic to the Life Care Center chain of nursing homes : “ Dozens of Life Care homes received below-average staffing ratings or were flagged during inspections for not having enough nurses to properly care for patients.
” But for all the problems with the Life Care Center chain , it would soon become clear that its experience would not be @ @ @ @ @ @ @ have been the first known US nursing home hit , it would not be the last .
Estimates vary , but analysts Gregg Girvan and Avik Roy found that as of June 29 , 50,779 of the 113,135 US deaths from Covid-19 ( or 45 percent ) were deaths of residents of nursing or long-term care facilities .
Their numbers suggest that about 2.5 percent of all nursing home residents have been killed by the disease ; in New Jersey , which is particularly hard hit , the share is over 11 percent @ @ @ @ @ @ @ disease being particularly lethal among older people , and an early acute shortage of personal protective equipment ( PPE ) like masks across the board .
Death rates have been high for seniors in general , not just those in nursing homes .
A CDC report found that as of July 1 , more than 80 percent of Covid-19 deaths were among people 65 and over .
But investigations have since revealed that the conditions at too many nursing homes were conducive to the coronavirus ’ s spread , abetted by both state @ @ @ @ @ @ @ .
Andrew Cuomo ( D ) ordered nursing homes to take in Covid-19 patients discharged from hospitals , contributing to superspreader events like one in Troy , New York , documented by ProPublica .
Connecticut Gov .
Ned Lamont ( D ) also signed executive orders offering partial legal immunity to nursing homes during the crisis , limiting families ’ abilities to seek redress when the state ’ s strategies failed .
An important context for these events , however , is federal policy .
Since well before the coronavirus pandemic , the @ @ @ @ @ @ @ the nursing home industry , pushing a deregulatory agenda that advocates say has worsened conditions for residents and will make them worse still in the pandemic era .
Covid-19 is a once-in-a-lifetime health crisis that is catching almost all institutions — and politicians , regardless of party — ill-prepared .
But there is no question that the administration , at the prodding of industry , has enacted and proposed moves aimed at easing regulations on nursing homes — moves that patient advocates have said were increasing health risks for residents well before Covid-19 @ @ @ @ @ @ @ for Medicare and Medicaid Services ( CMS ) , the federal agency that oversees Medicare and Medicaid , is in charge of regulating and overseeing the nursing home industry .
( The large majority of funding for nursing facilities comes from Medicaid or Medicare , meaning that CMS certification is a key prerequisite for most to function . )
The agency outsources the job of conducting inspections to state surveying agencies , operated by state governments .
Together , CMS and its surveyors are the main system of accountability for the 15,600-odd nursing @ @ @ @ @ @ @ million inhabitants .
The Trump CMS moved to curb fining nursing homes that were found violating regulations — in particular , regulations meant to prevent the spread of infectious disease .
Infection control deficiencies are by far the most cited regulatory failing in nursing homes , and the Trump administration has acted to reduce the amount of money fined , and to move away from a system of daily fines that experts say is more effective at changing facility behaviors .
( In the face of the coronavirus outbreak , the administration last @ @ @ @ @ @ @ more on this below . )
If the move to cut fines worries experts , future changes heralded by the Trump administration are even more concerning .
Under the Obama administration , the Centers for Medicare and Medicaid Services issued a rule requiring all facilities to employ a dedicated “ infection prevention specialist ” at least part time .
CMS Administrator Seema Verma has proposed rolling back that rule and only requiring such specialists to serve as consultants , potentially covering many different nursing facilities .
At the time it was proposed , @ @ @ @ @ @ @ and people with disabilities took note of the new rule , but it was largely ignored .
It wasn ’ t until March , when the pandemic hit , that the proposed rule change got attention in the mainstream press .
The rule still hasn ’ t taken effect , but will , barring unexpected changes to administration policy , if Trump is reelected .
The administration has also sought cuts to Medicaid ’ s budget that could negatively impact nursing homes , reduce funding for infection control , and likely worsen protections @ @ @ @ @ @ @ the Obama rule rollback , have not taken effect yet but could with a second Trump term .
“ I think the pandemic has revealed a lot of these serious problems , ” Toby Edelman , senior staff attorney for the Center for Medicare Advocacy and a veteran resident advocate on nursing home issues , says .
“ But whether the country will do better going forward — I don ’ t know.
” The Trump administration has decreased fines — in number and dollar amount — for nursing home violations The primary @ @ @ @ @ @ @ Services has for enforcing care standards at nursing homes is “ civil money penalties.
” These are essentially fines for facilities found not to be in compliance with CMS care standards .
These violations are identified through an annual , unannounced surveying process , conducted by state-level agencies with information then reported up to CMS .
Under the Trump administration , the average fine levied has fallen to $ 28,405 , from $ 41,260 in Obama ’ s final year in office , according to a 2019 analysis by Jordan Rau of Kaiser @ @ @ @ @ @ @ for incidents involving “ immediate jeopardy ” — the most serious designation — have fallen , Rau found , to about 18 percent less in Trump ’ s first year than they did in 2016 .
A finding of “ immediate jeopardy ” is just like the name implies : a situation in which noncompliance with regulations “ has placed the health and safety of recipients in its care at risk for serious injury , serious harm , serious impairment or death , ” per CMS ’ s guidelines .
One example highlighted @ @ @ @ @ @ @ Accountability Office , a congressional watchdog agency , illustrates what an instance of “ immediate jeopardy ” looks like : Civil money penalties ideally provide a strong financial incentive for nursing homes that put residents at risk of infection to change practices .
For that reason , toward the end of the Obama administration , CMS began requiring regional offices to impose penalties whenever residents were found to be in “ immediate jeopardy , ” instead of letting regulators decide whether to levy a fine .
Under Trump , CMS has gone to @ @ @ @ @ @ @ levy fines for “ immediate jeopardy ” violations .
Instead of an automatic fine , a regulator may just instruct the nursing home to change its practices or do a training .
( The June 1 rules removed some discretion around fining for infection control practices specifically , but civil money penalties are only allowed if facilities also had a previous infection control deficiency . )
In a newsletter for its “ Patients Over Paperwork ” initiative , meant to publicize deregulatory efforts , CMS explained that reduced fining came because of complaints @ @ @ @ @ @ @ applied consistently or fairly to nursing homes found out of compliance.
” The decline in fining can have serious implications for public health — especially in a pandemic .
By far the most common infraction identified in state-agency surveys is a failure of infection prevention , according to a recent report from the GAO .
From 2013 to 2017 , 82 percent of all surveyed nursing homes had an infection control deficiency in at least one surveyed year .
( The second most common deficiency , related to “ ensuring the environment is @ @ @ @ @ @ @ in 37 percent of homes . )
As it happens , the new rule requiring fines for “ immediate jeopardy ” late in the Obama administration meant that the total number of fines imposed actually went up at the beginning of the Trump administration : 3.5 percent of inspections resulted in fines in 2016 , compared to 4.7 percent in the early Trump administration .
On June 15 , 2018 , the Trump administration formally reversed this enforcement change .
Rau ’ s data analysis also highlighted an even more meaningful shift in @ @ @ @ @ @ @ day ” fining to “ per instance ” fining .
Per-instance fines became much more common under Trump as the result of a CMS policy change in July 2017 .
Per-day fining means that facilities have to pay up for each day they were found to be out of compliance with Medicare and Medicaid regulations .
Per-instance penalties , by contrast , apply to each time they get caught by surveyors .
The difference is easier to grasp with some examples .
The Unique Rehabilitation and Health Center , a nursing home close @ @ @ @ @ @ @ Washington , DC , was fined a total of $ 110,448.65 in 2017 on a per-day basis .
Among other problems , the district ’ s inspectors found that the home failed to do proper wound follow-up with a patient , leading to emergency surgery when the wound deteriorated .
That penalty was imposed on a per-day basis for 77 days , meaning the home was fined an average of $ 1,434.40 per day it was in violation of proper wound care and other policies .
By contrast , the BridgePoint Sub-Acute and @ @ @ @ @ @ @ in southwest DC , received a per-instance fine of $ 17,820.25 in 2017 .
District surveyors found that the home had placed residents in immediate jeopardy of harm by failing to properly freeze fish and beef , “ with puddles of bloody juices dripping onto the freezer floor.
” Instead of issuing penalties for every day the freezer was not at a low enough temperature , producing rancid meat for residents , the Centers for Medicare and Medicaid Services fined the company once on a per-instance basis .
The result was a much @ @ @ @ @ @ @ even though both were found to be putting residents at risk of serious harm .
Tellingly , Unique Rehabilitation was fined before the July policy change by the Trump administration ( on February 8 , 2017 ) and BridgePoint was fined after ( on October 20 , 2017 ) .
Some experts in the nursing home industry argue that per-instance fining provides a weaker incentive for nursing homes to improve .
“ The idea behind daily compliance is , if you don ’ t have a fire extinguisher , say , you ’ @ @ @ @ @ @ @ in place , and then the fines would stop , ” David Grabowski , an economist at Harvard Medical School who studies long-term care , told me .
“ It ’ s an effort to hold the facilities ’ feet to the fire in terms of improving something that ’ s out of compliance.
” The shift to per-instance fining weakens that regular incentive .
In a group letter to Congress in 2019 , a coalition of patient advocates — including the Center for Medicare Advocacy , Justice in Aging , the Long @ @ @ @ @ @ @ National Consumer Voice for Quality Long-Term Care — denounced CMS for lessening fines , arguing , “ These changes are counterproductive .
The threat of fines is a critical deterrent to abuse and substandard care , particularly when they are large enough to impact a facility ’ s actions.
” These changes in how nursing homes are fined have not happened in a vacuum .
The American Health Care Association , the biggest lobbying group for the nursing home industry , sent a letter to President-elect Trump in December 2016 urging him to @ @ @ @ @ @ @ requiring fines in “ immediate jeopardy ” cases .
“ We request that [ the fine requirement ] be repealed and that [ civil money penalties ] and other remedies be halted from being applied retrospectively , ” Mark Parkinson , AHCA ’ s president and CEO and a former Democratic governor of Kansas , wrote to Trump in the letter .
AHCA ’ s voice on this issue is powerful .
It dramatically ramped up its lobbying spending in the late Obama administration , per OpenSecrets , and spent about $ 23 @ @ @ @ @ @ @ , during the period of Obama ’ s regulatory ramp-up and Trump ’ s drawdown .
“ It ’ s time to recognize that when nursing homes receive citations , it ’ s a failure of CMS and the survey process .
Citations and fines without assistance will not help us keep residents and staff safe from this virus , ” AHCA ’ s Cristina Crawford told Vox in a statement .
“ Independent research shows COVID-19 outbreaks in long term care are not related to quality of care , past infection control @ @ @ @ @ @ @ a critical point to include in any piece along these lines .
This research shows the prevalence of COVID-19 in skilled nursing facilities is correlated to the COVID-19 rate in the community , the size of the facility , and proximity to an urban area.
” The decline in fining can have serious implications for public health — especially in a pandemic It ’ s important to note that the fall in fining might not have caused a decline in infection control at these facilities .
The situation was dire before Trump took @ @ @ @ @ @ @ in normal times , fining , in particular per-day fining , can be a powerful tool to get facilities in line — and particularly useful in heading off something like the coronavirus pandemic .
Indeed , as the Covid-19 pandemic continued , the Trump administration embraced fining for infection control .
And while that seems like a good move on paper , even experts who embrace per-day fines argue that compared to other things CMS could be doing to protect patients — like supporting increased staffing , testing , and PPE availability — @ @ @ @ @ @ @ , even if it was the right priority during a non-crisis time .
“ CMS should be doing two things .
First , they should be providing facilities with testing and personal protective equipment .
Second , they should be looking to provide education and guidance to facilities on best infection-control practices , ” Grabowski of Harvard Medical told Skilled Nursing News .
“ If the goal is to save lives and protect residents , then this is not the right enforcement action .
Facilities have limited resources right now.
” The bulk @ @ @ @ @ @ @ agenda has yet to be implemented Weak fining is one of the deregulatory actions most under the control of the Trump administration itself .
But it has also pushed changes to rules , laws , and appropriations that could exacerbate the infection control problem at nursing homes .
These changes , proposed before the pandemic , have not taken effect yet , and Covid-19 may yet change the administration ’ s mind .
But taken together , the proposed rules suggest an administration determined to ease infection control and public health regulations on @ @ @ @ @ @ @ these is rescinding the rule requiring part-time infection control specialists at nursing homes .
The requirement was an Obama-era initiative only issued as a final rule in September 2016 .
The measure would require that every nursing home have an infection control staffer ( most likely a registered nurse with specialized training on infection prevention ) on at least a part-time basis .
The Trump administration would instead allow homes to hire consultants spending much less time in each facility , potentially weakening infection control oversight .
Grabowski notes that because the measure @ @ @ @ @ @ @ empirical work on whether requiring an on-site infection preventionist ( the Obama approach ) works better than allowing contractors who work at multiple facilities ( the Trump model ) .
But Edelman of the Center for Medicare Advocacy argues the Obama requirement was an overdue reaction to a longtime failure of CMS to police infection control failures , as evidenced by the vast majority of facilities being cited for deficiencies on infection prevention .
“ I really thought this was one of the best things done in the final rules in 2016 , @ @ @ @ @ @ @ it was pretty much what [ Medicare advocates ] had said for 25 years.
” Rescinding it , he says , was a step backward .
The Trump administration has also proposed weakening protections in the Nursing Home Reform Act , the 1987 law that serves as the primary basis for CMS ’ s regulation of the sector .
CMS ’ s 2020 and 2021 budget requests both include an ask for Congress to end the mandate that nursing homes be surveyed annually .
Instead , top-performing nursing homes would only be required @ @ @ @ @ @ @ Verma , CMS ’ s administrator , has referred to this as a “ risk-based survey model , ” arguing that annual surveys are overly costly .
The danger here is that even “ top performers ” can have deep weaknesses , a fact underlined by the Covid-19 pandemic .
The City ’ s Susan Jaffe analyzed New York state ’ s inspections in March and April of New York City nursing homes , and found that 600 people have died of Covid-19 in nursing homes that were given a perfect record by @ @ @ @ @ @ @ happened as the pandemic progressed and yet did not identify any failures .
That should serve as a reminder that even “ low risk ” facilities can see failures , especially during pandemics like Covid-19 , and probably shouldn ’ t go without any oversight .
Cuts to Medicaid budgets could further harm nursing homes Finally , the Trump administration is also pushing for budgetary changes that affect nursing homes — and could be deleterious for infection control efforts in those settings .
The administration ’ s efforts to defund Medicaid are less @ @ @ @ @ @ @ nursing homes from onerous regulations , but they could weaken access to care and harm quality at facilities all the same .
In particular , the administration has tried to convert Medicaid into a block grant .
A report by the Commonwealth Fund suggests that a block grant as designed by the Trump administration would reduce Medicaid spending by $ 110 billion over five years , or about 10 percent .
As the Center for Medicare Advocacy has noted , such a shift could reduce access to nursing care and increase risk to @ @ @ @ @ @ @ instance , nursing homes that choose to accept Medicaid are currently required to accept Medicaid reimbursement as their full payment and not demand additional funds from patients ; that rule goes away with a block grant .
Rules requiring adequate training for staff ( including training in infection control ) could also go away , as could rules guaranteeing eligibility for qualifying residents .
Lowering funding for nursing homes can also put pressure on staffing , reducing the number of staff available and lowering their pay .
Nursing homes tend to be understaffed @ @ @ @ @ @ @ on Medicaid , already the least generous payer they take , could make matters even worse .
“ The payments side of this has some shortfalls , which leads to real workforce shortages , ” Grabowski says .
“ Many of these buildings lack staff and pay their staff , the direct caregivers , close to minimum wage .
That ’ s just a huge part of the expenditures — 60 to 70 percent of expenditures are labor.
” In a period when we need workers in hot spots to observe public health @ @ @ @ @ @ @ against those efforts .
Economist Krista Ruffini has used changes in the minimum wage to estimate that nursing homes with higher wages have fewer health code violations , fewer incidences of bedsores among residents , and lower mortality ; she estimates that a 10 percent increase in the minimum wage could prevent 15,000 to 16,000 deaths a year .
Lower wages , by contrast , could lower care quality at the potential cost of lives .
Other studies have found staffing levels at nursing homes are also related to mortality , suggesting that @ @ @ @ @ @ @ homes could also be deadly .
Lowering wages can also be particularly dangerous for infection control in another way : It could force staff to take other jobs to get by .
At the Life Care Center in Kirkland , Washington , CDC researchers have specifically cited the phenomenon of staffers working at multiple nursing homes as contributing to the pandemic .
Lower reimbursements that lead to lower wages could exacerbate this problem .
Lack of in-person surveying during the pandemic has public health experts concerned The Centers for Medicare and Medicaid Services @ @ @ @ @ @ @ of infection control violations was only one item in a string of policy changes the Trump administration has announced through the agency as Covid-19 ripped through the country .
On March 20 , CMS announced it would halt all state surveys of facilities .
Instead , it would only conduct targeted infection control surveys , and surveys in cases involving immediate jeopardy to patients , during the pandemic .
These targeted surveys found major failings .
( On March 30 , they reported that 36 percent of facilities surveyed failed to follow proper @ @ @ @ @ @ @ PPE properly . )
On April 15 , they increased payments for Covid-19 tests to try to accelerate testing availability at nursing homes .
On April 19 , they announced a new requirement that nursing homes report any Covid-19 cases and deaths .
By May 18 , they were already providing guidance about how to relax restrictions on visitation amid the crisis .
And on June 1 , they announced the new heightened infection control penalties .
The administration has painted these as ramping up enforcement and oversight .
But experts say these @ @ @ @ @ @ @ and regulation .
“ Initially I was very supportive of the pivot that CMS did from the typical survey and certification to focus only on infection control , ” Grabowski says .
But as time has worn on , he ’ s grown concerned over the lack of in-person access to facilities , either by state surveyors or by an even more important monitoring source : family , who along with staff members are the most frequent source of complaints and referrals of nursing homes to regulators .
Due to Covid-19 concerns , @ @ @ @ @ @ @ facilities , which makes failures of infection control and other regulatory lapses invisible to residents ’ biggest outside advocates .
Edelman notes much of the surveying during the pandemic has been done remotely , through videoconferencing software , which greatly limits what staff can pick up .
But her biggest concern is that the federal government and CMS are not pairing surveys on infection control with an effort to get testing and other resources to nursing homes in a timely manner , a failure that continued with the June 1 announcement of more @ @ @ @ @ @ @ and PPE .
“ In terms of getting testing to facilities or making sure everyone has equipment , setting standards for Covid-only facilities , the feds pretty much say the states are on their own , ” Edelman explains .
“ Our contact at CMS has said this twice : that the pandemic is locally executed , state-managed , and federally supported .
They ’ re pushing responsibility onto the states.
” Shunting responsibility is a theme when it comes to managing nursing homes .
In 2010 , the moral philosopher Kwame Anthony @ @ @ @ @ @ @ he believed people in the distant future will condemn our generation of humanity for , much as people in the 21st century condemn slavery or the denial of women ’ s suffrage .
The abandonment of older Americans in nursing homes was near the top of his list .
“ When we see old people who , despite many living relatives , suffer growing isolation , we know something is wrong , ” Appiah wrote .
But the situation is worse than “ isolation.
” It ’ s one of neglect in the @ @ @ @ @ @ @ by residents in these facilities every day .
Bioethicist Charles Camosy has cited nursing homes as a place where our “ throwaway culture ” thrives , only with human lives rather than consumer goods .
The Trump administration is not solely responsible for the pandemic ’ s ravaging of nursing homes .
But it has certainly contributed to the neglect that Appiah laments .

Few places represent the calamity of the Covid-19 pandemic as well as the Life Care Center of Kirkland.
Starting in February and escalating into early March, the nursing home in a Seattle suburb became one of the disease’s first hot spots in the United States. By March 9, more than a week before any state had issued a stay-at-home order, the Kirkland facility already had 129 cases (81 among residents; the rest among staff and visitors) and 23 deaths from the novel coronavirus, according to a Centers for Disease Control and Prevention report.
Before long, it became clear that practices at the Kirkland facility contributed to the spread of the virus there, according to federal inspectors. A Washington Post investigation found that the problems were endemic to the Life Care Center chain of nursing homes: “Dozens of Life Care homes received below-average staffing ratings or were flagged during inspections for not having enough nurses to properly care for patients.”
But for all the problems with the Life Care Center chain, it would soon become clear that its experience would not be unique. While the Kirkland facility may have been the first known US nursing home hit, it would not be the last.
Estimates vary, but analysts Gregg Girvan and Avik Roy found that as of June 29, 50,779 of the 113,135 US deaths from Covid-19 (or 45 percent) were deaths of residents of nursing or long-term care facilities. Their numbers suggest that about 2.5 percent of all nursing home residents have been killed by the disease; in New Jersey, which is particularly hard hit, the share is over 11 percent.
This is partially due to the disease being particularly lethal among older people, and an early acute shortage of personal protective equipment (PPE) like masks across the board. Death rates have been high for seniors in general, not just those in nursing homes. A CDC report found that as of July 1, more than 80 percent of Covid-19 deaths were among people 65 and over.
But investigations have since revealed that the conditions at too many nursing homes were conducive to the coronavirus’s spread, abetted by both state and federal policies. New York Gov. Andrew Cuomo (D) ordered nursing homes to take in Covid-19 patients discharged from hospitals, contributing to superspreader events like one in Troy, New York, documented by ProPublica. Connecticut Gov. Ned Lamont (D) also signed executive orders offering partial legal immunity to nursing homes during the crisis, limiting families’ abilities to seek redress when the state’s strategies failed.
An important context for these events, however, is federal policy. Since well before the coronavirus pandemic, the Trump administration has been targeting regulations in the nursing home industry, pushing a deregulatory agenda that advocates say has worsened conditions for residents and will make them worse still in the pandemic era.
Covid-19 is a once-in-a-lifetime health crisis that is catching almost all institutions — and politicians, regardless of party — ill-prepared. But there is no question that the administration, at the prodding of industry, has enacted and proposed moves aimed at easing regulations on nursing homes — moves that patient advocates have said were increasing health risks for residents well before Covid-19 came to the US.
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The Centers for Medicare and Medicaid Services (CMS), the federal agency that oversees Medicare and Medicaid, is in charge of regulating and overseeing the nursing home industry. (The large majority of funding for nursing facilities comes from Medicaid or Medicare, meaning that CMS certification is a key prerequisite for most to function.) The agency outsources the job of conducting inspections to state surveying agencies, operated by state governments. Together, CMS and its surveyors are the main system of accountability for the 15,600-odd nursing homes in the US and their 1.3 million inhabitants.
The Trump CMS moved to curb fining nursing homes that were found violating regulations — in particular, regulations meant to prevent the spread of infectious disease. Infection control deficiencies are by far the most cited regulatory failing in nursing homes, and the Trump administration has acted to reduce the amount of money fined, and to move away from a system of daily fines that experts say is more effective at changing facility behaviors. (In the face of the coronavirus outbreak, the administration last month announced it would increase fines; more on this below.)
If the move to cut fines worries experts, future changes heralded by the Trump administration are even more concerning. Under the Obama administration, the Centers for Medicare and Medicaid Services issued a rule requiring all facilities to employ a dedicated “infection prevention specialist” at least part time. CMS Administrator Seema Verma has proposed rolling back that rule and only requiring such specialists to serve as consultants, potentially covering many different nursing facilities.
At the time it was proposed, trade publications and some advocates for seniors and people with disabilities took note of the new rule, but it was largely ignored. It wasn’t until March, when the pandemic hit, that the proposed rule change got attention in the mainstream press. The rule still hasn’t taken effect, but will, barring unexpected changes to administration policy, if Trump is reelected.
The administration has also sought cuts to Medicaid’s budget that could negatively impact nursing homes, reduce funding for infection control, and likely worsen protections for residents. These changes, like the Obama rule rollback, have not taken effect yet but could with a second Trump term.
“I think the pandemic has revealed a lot of these serious problems,” Toby Edelman, senior staff attorney for the Center for Medicare Advocacy and a veteran resident advocate on nursing home issues, says. “But whether the country will do better going forward — I don’t know.”
The Trump administration has decreased fines — in number and dollar amount — for nursing home violations
The primary tool the Centers for Medicare and Medicaid Services has for enforcing care standards at nursing homes is “civil money penalties.” These are essentially fines for facilities found not to be in compliance with CMS care standards. These violations are identified through an annual, unannounced surveying process, conducted by state-level agencies with information then reported up to CMS.
Under the Trump administration, the average fine levied has fallen to $28,405, from $41,260 in Obama’s final year in office, according to a 2019 analysis by Jordan Rau of Kaiser Health News.
Moreover, average fines for incidents involving “immediate jeopardy” — the most serious designation — have fallen, Rau found, to about 18 percent less in Trump’s first year than they did in 2016. A finding of “immediate jeopardy” is just like the name implies: a situation in which noncompliance with regulations “has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death,” per CMS’s guidelines.
One example highlighted by a recent report from the Government Accountability Office, a congressional watchdog agency, illustrates what an instance of “immediate jeopardy” looks like:
A New York nursing home experienced a respiratory infection outbreak that sickened 38 residents. The nursing home did not maintain a complete and accurate list of those who were sick, did not isolate residents with symptoms from residents who were symptom-free—nor did it isolate staff members helping sick patients—and continued to allow residents to eat in the community dining room.
Civil money penalties ideally provide a strong financial incentive for nursing homes that put residents at risk of infection to change practices. For that reason, toward the end of the Obama administration, CMS began requiring regional offices to impose penalties whenever residents were found to be in “immediate jeopardy,” instead of letting regulators decide whether to levy a fine.
Under Trump, CMS has gone to a system of giving regulators discretion to levy fines for “immediate jeopardy” violations. Instead of an automatic fine, a regulator may just instruct the nursing home to change its practices or do a training. (The June 1 rules removed some discretion around fining for infection control practices specifically, but civil money penalties are only allowed if facilities also had a previous infection control deficiency.)
In a newsletter for its “Patients Over Paperwork” initiative, meant to publicize deregulatory efforts, CMS explained that reduced fining came because of complaints that civil money penalties “are not applied consistently or fairly to nursing homes found out of compliance.”
The decline in fining can have serious implications for public health — especially in a pandemic. By far the most common infraction identified in state-agency surveys is a failure of infection prevention, according to a recent report from the GAO. From 2013 to 2017, 82 percent of all surveyed nursing homes had an infection control deficiency in at least one surveyed year. (The second most common deficiency, related to “ensuring the environment is free from accidents,” was identified in 37 percent of homes.)
As it happens, the new rule requiring fines for “immediate jeopardy” late in the Obama administration meant that the total number of fines imposed actually went up at the beginning of the Trump administration: 3.5 percent of inspections resulted in fines in 2016, compared to 4.7 percent in the early Trump administration. On June 15, 2018, the Trump administration formally reversed this enforcement change.
Rau’s data analysis also highlighted an even more meaningful shift in policy under Trump: from “per day” fining to “per instance” fining. Per-instance fines became much more common under Trump as the result of a CMS policy change in July 2017. Per-day fining means that facilities have to pay up for each day they were found to be out of compliance with Medicare and Medicaid regulations. Per-instance penalties, by contrast, apply to each time they get caught by surveyors.
The difference is easier to grasp with some examples. The Unique Rehabilitation and Health Center, a nursing home close to Union Station and the Capitol in Washington, DC, was fined a total of $110,448.65 in 2017 on a per-day basis. Among other problems, the district’s inspectors found that the home failed to do proper wound follow-up with a patient, leading to emergency surgery when the wound deteriorated. That penalty was imposed on a per-day basis for 77 days, meaning the home was fined an average of $1,434.40 per day it was in violation of proper wound care and other policies.
By contrast, the BridgePoint Sub-Acute and Rehabilitation National Harbor, a nursing home in southwest DC, received a per-instance fine of $17,820.25 in 2017. District surveyors found that the home had placed residents in immediate jeopardy of harm by failing to properly freeze fish and beef, “with puddles of bloody juices dripping onto the freezer floor.” Instead of issuing penalties for every day the freezer was not at a low enough temperature, producing rancid meat for residents, the Centers for Medicare and Medicaid Services fined the company once on a per-instance basis.
The result was a much lower fine than Unique Rehabilitation received, even though both were found to be putting residents at risk of serious harm. Tellingly, Unique Rehabilitation was fined before the July policy change by the Trump administration (on February 8, 2017) and BridgePoint was fined after (on October 20, 2017).
Some experts in the nursing home industry argue that per-instance fining provides a weaker incentive for nursing homes to improve.
“The idea behind daily compliance is, if you don’t have a fire extinguisher, say, you’d be fined until you get it in place, and then the fines would stop,” David Grabowski, an economist at Harvard Medical School who studies long-term care, told me. “It’s an effort to hold the facilities’ feet to the fire in terms of improving something that’s out of compliance.” The shift to per-instance fining weakens that regular incentive.
In a group letter to Congress in 2019, a coalition of patient advocates — including the Center for Medicare Advocacy, Justice in Aging, the Long Term Care Community Coalition, and the National Consumer Voice for Quality Long-Term Care — denounced CMS for lessening fines, arguing, “These changes are counterproductive. The threat of fines is a critical deterrent to abuse and substandard care, particularly when they are large enough to impact a facility’s actions.”
These changes in how nursing homes are fined have not happened in a vacuum. The American Health Care Association, the biggest lobbying group for the nursing home industry, sent a letter to President-elect Trump in December 2016 urging him to reverse many Obama administration initiatives, like requiring fines in “immediate jeopardy” cases. “We request that [the fine requirement] be repealed and that [civil money penalties] and other remedies be halted from being applied retrospectively,” Mark Parkinson, AHCA’s president and CEO and a former Democratic governor of Kansas, wrote to Trump in the letter.
AHCA’s voice on this issue is powerful. It dramatically ramped up its lobbying spending in the late Obama administration, per OpenSecrets, and spent about $23 million on lobbying from 2014 to 2019, during the period of Obama’s regulatory ramp-up and Trump’s drawdown.
“It’s time to recognize that when nursing homes receive citations, it’s a failure of CMS and the survey process. Citations and fines without assistance will not help us keep residents and staff safe from this virus,” AHCA’s Cristina Crawford told Vox in a statement. “Independent research shows COVID-19 outbreaks in long term care are not related to quality of care, past infection control and many other factors. It is a critical point to include in any piece along these lines. This research shows the prevalence of COVID-19 in skilled nursing facilities is correlated to the COVID-19 rate in the community, the size of the facility, and proximity to an urban area.”
(The research AHCA refers to is preliminary: Some studies have found no relationship between a facility’s “star rating” from CMS, an indication of its quality based on past violations, and its Covid-19 record, while others have found a relationship between facility quality and Covid-19 deaths.)
The decline in fining can have serious implications for public health — especially in a pandemic
It’s important to note that the fall in fining might not have caused a decline in infection control at these facilities. The situation was dire before Trump took office. But patient advocates agree that in normal times, fining, in particular per-day fining, can be a powerful tool to get facilities in line — and particularly useful in heading off something like the coronavirus pandemic.
Indeed, as the Covid-19 pandemic continued, the Trump administration embraced fining for infection control. And while that seems like a good move on paper, even experts who embrace per-day fines argue that compared to other things CMS could be doing to protect patients — like supporting increased staffing, testing, and PPE availability — fining is the wrong priority right now, even if it was the right priority during a non-crisis time.
“CMS should be doing two things. First, they should be providing facilities with testing and personal protective equipment. Second, they should be looking to provide education and guidance to facilities on best infection-control practices,” Grabowski of Harvard Medical told Skilled Nursing News. “If the goal is to save lives and protect residents, then this is not the right enforcement action. Facilities have limited resources right now.”
The bulk of Trump’s defunding and deregulatory agenda has yet to be implemented
Weak fining is one of the deregulatory actions most under the control of the Trump administration itself. But it has also pushed changes to rules, laws, and appropriations that could exacerbate the infection control problem at nursing homes.
These changes, proposed before the pandemic, have not taken effect yet, and Covid-19 may yet change the administration’s mind. But taken together, the proposed rules suggest an administration determined to ease infection control and public health regulations on nursing homes.
The most significant of these is rescinding the rule requiring part-time infection control specialists at nursing homes. The requirement was an Obama-era initiative only issued as a final rule in September 2016. The measure would require that every nursing home have an infection control staffer (most likely a registered nurse with specialized training on infection prevention) on at least a part-time basis. The Trump administration would instead allow homes to hire consultants spending much less time in each facility, potentially weakening infection control oversight.
Grabowski notes that because the measure is so recent, we have no empirical work on whether requiring an on-site infection preventionist (the Obama approach) works better than allowing contractors who work at multiple facilities (the Trump model).
But Edelman of the Center for Medicare Advocacy argues the Obama requirement was an overdue reaction to a longtime failure of CMS to police infection control failures, as evidenced by the vast majority of facilities being cited for deficiencies on infection prevention.
“I really thought this was one of the best things done in the final rules in 2016,” Edelman says. “Most of it was pretty much what [Medicare advocates] had said for 25 years.” Rescinding it, he says, was a step backward.
The Trump administration has also proposed weakening protections in the Nursing Home Reform Act, the 1987 law that serves as the primary basis for CMS’s regulation of the sector. CMS’s 2020 and 2021 budget requests both include an ask for Congress to end the mandate that nursing homes be surveyed annually. Instead, top-performing nursing homes would only be required to be surveyed every 30 months. Verma, CMS’s administrator, has referred to this as a “risk-based survey model,” arguing that annual surveys are overly costly.
The danger here is that even “top performers” can have deep weaknesses, a fact underlined by the Covid-19 pandemic. The City’s Susan Jaffe analyzed New York state’s inspections in March and April of New York City nursing homes, and found that 600 people have died of Covid-19 in nursing homes that were given a perfect record by surveyors. Surveys of their infection control happened as the pandemic progressed and yet did not identify any failures. That should serve as a reminder that even “low risk” facilities can see failures, especially during pandemics like Covid-19, and probably shouldn’t go without any oversight.
Cuts to Medicaid budgets could further harm nursing homes
Finally, the Trump administration is also pushing for budgetary changes that affect nursing homes — and could be deleterious for infection control efforts in those settings.
The administration’s efforts to defund Medicaid are less directly part of an effort to spare nursing homes from onerous regulations, but they could weaken access to care and harm quality at facilities all the same. In particular, the administration has tried to convert Medicaid into a block grant. A report by the Commonwealth Fund suggests that a block grant as designed by the Trump administration would reduce Medicaid spending by $110 billion over five years, or about 10 percent. As the Center for Medicare Advocacy has noted, such a shift could reduce access to nursing care and increase risk to patients by eliminating consumer protections.
For instance, nursing homes that choose to accept Medicaid are currently required to accept Medicaid reimbursement as their full payment and not demand additional funds from patients; that rule goes away with a block grant. Rules requiring adequate training for staff (including training in infection control) could also go away, as could rules guaranteeing eligibility for qualifying residents.
Lowering funding for nursing homes can also put pressure on staffing, reducing the number of staff available and lowering their pay. Nursing homes tend to be understaffed as it is, and a squeeze on Medicaid, already the least generous payer they take, could make matters even worse. “The payments side of this has some shortfalls, which leads to real workforce shortages,” Grabowski says. “Many of these buildings lack staff and pay their staff, the direct caregivers, close to minimum wage. That’s just a huge part of the expenditures — 60 to 70 percent of expenditures are labor.”
In a period when we need workers in hot spots to observe public health guidelines closely, such shortages could cut against those efforts.
Economist Krista Ruffini has used changes in the minimum wage to estimate that nursing homes with higher wages have fewer health code violations, fewer incidences of bedsores among residents, and lower mortality; she estimates that a 10 percent increase in the minimum wage could prevent 15,000 to 16,000 deaths a year. Lower wages, by contrast, could lower care quality at the potential cost of lives. Other studies have found staffing levels at nursing homes are also related to mortality, suggesting that Medicaid cuts that cascade down to nursing homes could also be deadly.
Lowering wages can also be particularly dangerous for infection control in another way: It could force staff to take other jobs to get by. At the Life Care Center in Kirkland, Washington, CDC researchers have specifically cited the phenomenon of staffers working at multiple nursing homes as contributing to the pandemic. Lower reimbursements that lead to lower wages could exacerbate this problem.
Lack of in-person surveying during the pandemic has public health experts concerned
The Centers for Medicare and Medicaid Services’ June 1 announcement of ramped-up enforcement of infection control violations was only one item in a string of policy changes the Trump administration has announced through the agency as Covid-19 ripped through the country.
On March 20, CMS announced it would halt all state surveys of facilities. Instead, it would only conduct targeted infection control surveys, and surveys in cases involving immediate jeopardy to patients, during the pandemic. These targeted surveys found major failings. (On March 30, they reported that 36 percent of facilities surveyed failed to follow proper hand-washing and a quarter failed to use PPE properly.)
On April 15, they increased payments for Covid-19 tests to try to accelerate testing availability at nursing homes. On April 19, they announced a new requirement that nursing homes report any Covid-19 cases and deaths. By May 18, they were already providing guidance about how to relax restrictions on visitation amid the crisis. And on June 1, they announced the new heightened infection control penalties.
The administration has painted these as ramping up enforcement and oversight. But experts say these decisions have overall translated to less oversight and regulation.
“Initially I was very supportive of the pivot that CMS did from the typical survey and certification to focus only on infection control,” Grabowski says. But as time has worn on, he’s grown concerned over the lack of in-person access to facilities, either by state surveyors or by an even more important monitoring source: family, who along with staff members are the most frequent source of complaints and referrals of nursing homes to regulators. Due to Covid-19 concerns, these family members are usually barred from facilities, which makes failures of infection control and other regulatory lapses invisible to residents’ biggest outside advocates.
Edelman notes much of the surveying during the pandemic has been done remotely, through videoconferencing software, which greatly limits what staff can pick up.
But her biggest concern is that the federal government and CMS are not pairing surveys on infection control with an effort to get testing and other resources to nursing homes in a timely manner, a failure that continued with the June 1 announcement of more penalties but not more aid for testing and PPE.
“In terms of getting testing to facilities or making sure everyone has equipment, setting standards for Covid-only facilities, the feds pretty much say the states are on their own,” Edelman explains. “Our contact at CMS has said this twice: that the pandemic is locally executed, state-managed, and federally supported. They’re pushing responsibility onto the states.”
Shunting responsibility is a theme when it comes to managing nursing homes. In 2010, the moral philosopher Kwame Anthony Appiah made a list of practices that he believed people in the distant future will condemn our generation of humanity for, much as people in the 21st century condemn slavery or the denial of women’s suffrage. The abandonment of older Americans in nursing homes was near the top of his list.
“When we see old people who, despite many living relatives, suffer growing isolation, we know something is wrong,” Appiah wrote. But the situation is worse than “isolation.” It’s one of neglect in the face of real, life-and-death dangers faced by residents in these facilities every day. Bioethicist Charles Camosy has cited nursing homes as a place where our “throwaway culture” thrives, only with human lives rather than consumer goods.
The Trump administration is not solely responsible for the pandemic’s ravaging of nursing homes. But it has certainly contributed to the neglect that Appiah laments.


vox--2020-07-14--Air Force veteran MJ Hegar wins the Texas Democratic Senate primary

Air Force veteran Mary Jennings “ MJ ” Hegar will officially face Sen. John Cornyn in November after winning out against state Sen. Royce West in Texas ’ s Democratic primary runoff on Tuesday .
Hegar secured the endorsement not just from the Democratic Senatorial Campaign Committee but also from major national groups including EMILY ’ s List , Everytown for Gun Safety , and the Planned Parenthood Action Fund .
She has long been the anointed candidate to take on Cornyn , and she was the top vote-getter in Texas ’ s Super Tuesday primary in March .
On @ @ @ @ @ @ @ a progressive fixture of Democratic politics in Texas .
In the lead-up to the runoff , Hegar and her allies spent heavily to make sure they put the race away : According to the Texas Tribune , she , along with the DSCC and EMILY ’ s List , poured at least $ 2 million into ads in the Houston area over the last week of the race , outspending West 85 to 1 .
That kind of spending might well have been necessary .
According to Mark Jones , a political science @ @ @ @ @ @ @ been gaining traction in the race , though Tuesday ’ s result shows it didn ’ t happen quite fast enough to get him over the line .
In particular , Jones said , the national movement following the death of George Floyd in Minneapolis gave West a lift .
“ African American officeholders and political elites in the state , ” he said , began to “ really rally behind West in a way that they hadn ’ t in the original primary in March.
” Hegar was always the favorite , @ @ @ @ @ @ @ the general election against Cornyn with about $ 1.6 million in the bank and a steep climb ahead of her .
The Cook Political Report rates the Texas Senate race as “ Likely R , ” and Jones said he believes that ’ s “ still pretty safe.
” Texas is becoming less of a sure thing for Republicans : FiveThirtyEight ’ s polling average shows President Donald Trump in a dead-heat tie with Democratic nominee Joe Biden in the state , and one-time presidential candidate Beto O ’ Rourke came within a @ @ @ @ @ @ @ Cruz in 2018 .
But Cornyn looks to be somewhat more popular in the state than his colleague in the Senate , never mind the president , and he ’ s running anywhere from 8 to 13 points ahead of Hegar in recent polling , so she ’ ll have her work cut out for her .
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Air Force veteran Mary Jennings “MJ” Hegar will officially face Sen. John Cornyn in November after winning out against state Sen. Royce West in Texas’s Democratic primary runoff on Tuesday.
Hegar secured the endorsement not just from the Democratic Senatorial Campaign Committee but also from major national groups including EMILY’s List, Everytown for Gun Safety, and the Planned Parenthood Action Fund. She has long been the anointed candidate to take on Cornyn, and she was the top vote-getter in Texas’s Super Tuesday primary in March.
On Tuesday, she again defeated West, a progressive fixture of Democratic politics in Texas. In the lead-up to the runoff, Hegar and her allies spent heavily to make sure they put the race away: According to the Texas Tribune, she, along with the DSCC and EMILY’s List, poured at least $2 million into ads in the Houston area over the last week of the race, outspending West 85 to 1.
That kind of spending might well have been necessary. According to Mark Jones, a political science fellow at Rice University, West had been gaining traction in the race, though Tuesday’s result shows it didn’t happen quite fast enough to get him over the line.
In particular, Jones said, the national movement following the death of George Floyd in Minneapolis gave West a lift. “African American officeholders and political elites in the state,” he said, began to “really rally behind West in a way that they hadn’t in the original primary in March.”
Hegar was always the favorite, however, and now she heads into the general election against Cornyn with about $1.6 million in the bank and a steep climb ahead of her. The Cook Political Report rates the Texas Senate race as “Likely R,” and Jones said he believes that’s “still pretty safe.”
Texas is becoming less of a sure thing for Republicans: FiveThirtyEight’s polling average shows President Donald Trump in a dead-heat tie with Democratic nominee Joe Biden in the state, and one-time presidential candidate Beto O’Rourke came within a few points of unseating Republican Sen. Ted Cruz in 2018.
But Cornyn looks to be somewhat more popular in the state than his colleague in the Senate, never mind the president, and he’s running anywhere from 8 to 13 points ahead of Hegar in recent polling, so she’ll have her work cut out for her.


vox--2020-07-14--Tommy Tuberville wins the Alabama GOP Senate primary, defeating Jeff Sessions

Former Auburn University football coach Tommy Tuberville defeated former Attorney General Jeff Sessions in Alabama ’ s Republican primary runoff election on Tuesday , setting up a November match against current Democratic Sen. Doug Jones , who became the first Democrat to win a Senate seat in the state since 1992 when he defeated Roy Moore , who has been accused of child molestation , in a 2017 special election .
In a state Donald Trump won handily in 2016 , Tuberville is favored to win in November .
Tuberville has never served in elected office ( and moved to @ @ @ @ @ @ @ and his campaign against Sessions was largely based on his support for the president .
Trump endorsed Tuberville in March , tweeting , “ Tommy was a terrific head football coach at Auburn University .
He is a REAL LEADER who will never let MAGA/KAG , or our Country , down !
” On a Monday call with Alabama voters , Trump said of Tuberville , “ He ’ s going to have a cold , direct line into my office .
That I can tell you.
” Whether Tuberville was a “ @ @ @ @ @ @ @ a matter of some debate , but his close ties to college football — in a state where football is king — played a big role in his campaign against Sessions .
I spoke to Bill Britt , editor-in-chief of the Alabama Political Reporter , who told me that while Sessions was enmeshed in his first real campaign since the mid-1990s , “ Tuberville , who is a decade younger and appears to be much more vital , is proving to be very good at one-on-one politicking.
” Britt added that Tuberville ’ @ @ @ @ @ @ @ off in a new arena .
“ Years of recruiting players and back-slapping wealthy alumni has given him a far greater ability to reach people in rural Alabama , ” Britt said .
“ A Republican has to win rural Alabama to win any primary.
” Tuberville ’ s football past could play a surprisingly big part in November ’ s general election .
Though he gained national attention for leading the Auburn Tigers to an undefeated season in 2004 , five years earlier he handed down a one-game suspension to a player @ @ @ @ @ @ @ of a 15-year-old girl .
Despite the player pleading guilty to contributing to the delinquency of a minor , Tuberville permitted the player to remain on the team .
Tuberville also abandoned Texas Tech recruits and assistant coaches mid-dinner in 2012 , the night before he announced he would take a new job at the University of Cincinnati .
And then there was his infamous radio appearance in 1998 when , as then-head coach at the University of Mississippi , he promised he would only leave the job “ in a pine box @ @ @ @ @ @ @ two days later to become head coach of the Tigers .
On the field , as Sessions ’ s campaign noted on Twitter , Tuberville ’ s stints at Auburn , Texas Tech , and Cincinnati did not end successfully .
“ He was the leader of a team that went bad , ” Sessions said July 11 .
Whether he ’ ll serve his team well in November remains to be seen .
Every day at Vox , we aim to answer your most important questions and provide you , and our @ @ @ @ @ @ @ that has the power to save lives .
Our mission has never been more vital than it is in this moment : to empower you through understanding .
Vox ’ s work is reaching more people than ever , but our distinctive brand of explanatory journalism takes resources — particularly during a pandemic and an economic downturn .
Your financial contribution will not constitute a donation , but it will enable our staff to continue to offer free articles , videos , and podcasts at the quality and volume that this moment requires @ @ @ @ @ @ @ Vox today .

Former Auburn University football coach Tommy Tuberville defeated former Attorney General Jeff Sessions in Alabama’s Republican primary runoff election on Tuesday, setting up a November match against current Democratic Sen. Doug Jones, who became the first Democrat to win a Senate seat in the state since 1992 when he defeated Roy Moore, who has been accused of child molestation, in a 2017 special election.
In a state Donald Trump won handily in 2016, Tuberville is favored to win in November.
Tuberville has never served in elected office (and moved to Alabama only two years ago), and his campaign against Sessions was largely based on his support for the president. Trump endorsed Tuberville in March, tweeting, “Tommy was a terrific head football coach at Auburn University. He is a REAL LEADER who will never let MAGA/KAG, or our Country, down!” On a Monday call with Alabama voters, Trump said of Tuberville, “He’s going to have a cold, direct line into my office. That I can tell you.”
Whether Tuberville was a “terrific” football coach at Auburn is a matter of some debate, but his close ties to college football — in a state where football is king — played a big role in his campaign against Sessions. I spoke to Bill Britt, editor-in-chief of the Alabama Political Reporter, who told me that while Sessions was enmeshed in his first real campaign since the mid-1990s, “Tuberville, who is a decade younger and appears to be much more vital, is proving to be very good at one-on-one politicking.”
Britt added that Tuberville’s college football experience was perhaps paying off in a new arena. “Years of recruiting players and back-slapping wealthy alumni has given him a far greater ability to reach people in rural Alabama,” Britt said. “A Republican has to win rural Alabama to win any primary.”
Tuberville’s football past could play a surprisingly big part in November’s general election. Though he gained national attention for leading the Auburn Tigers to an undefeated season in 2004, five years earlier he handed down a one-game suspension to a player who was charged with the second-degree rape of a 15-year-old girl. Despite the player pleading guilty to contributing to the delinquency of a minor, Tuberville permitted the player to remain on the team.
Tuberville also abandoned Texas Tech recruits and assistant coaches mid-dinner in 2012, the night before he announced he would take a new job at the University of Cincinnati. And then there was his infamous radio appearance in 1998 when, as then-head coach at the University of Mississippi, he promised he would only leave the job “in a pine box” — and then flew to Auburn two days later to become head coach of the Tigers.
On the field, as Sessions’s campaign noted on Twitter, Tuberville’s stints at Auburn, Texas Tech, and Cincinnati did not end successfully. “He was the leader of a team that went bad,” Sessions said July 11.
Whether he’ll serve his team well in November remains to be seen.