Policy discussions regarding COVID-19 in the U.S., and in other countries, are now moving away from a crisis pandemic stance and towards a return to more normal conditions in education, travel, business, and government. In the U.S. particularly this would mean that President Biden would not renew his national emergency declaration when it ends on March 1, 2022. This seems appropriate for most segments of society now that vaccines, boosters, and effective disease treatments are available, and natural immunity is developing. Though we still need to consider whether more can be done to protect the most vulnerable segments of our society at risk from COVID-19, and those hardest hit at the beginning of the pandemic: the elderly, and, especially, residents and staff in nursing homes. A targeted mix of mandates and incentives with culturally aware effective outreach is appropriate for this group.
The highest mortality during the pandemic has been concentrated among the elderly, and an exponential relationship between age and the infection fatality ratio of COVID-19 has been well established through research studies and data analysis. The close living arrangements within nursing homes exacerbated that tendency, resulting initially in very high mortality from COVID-19 in these settings. The vector of infection often came from staff. In the absence of vaccines, effective medical treatment, and natural immunity, various non-pharmaceutical interventions were imposed by governments on general society and nursing homes. The evidence of their effectiveness is modest and mixed, although they seemed to have temporary reduced COVID-19 deaths. But the price of these socially isolating interventions was high, increasing other causes of death in nursing homes, such as Alzheimer’s. With the availability of vaccines, and more recently boosters which have proven effective at reducing hospitalizations and deaths, it is essential to now focus on the elderly, nursing home residents, and their caregivers, to determine how to reduce these excessive deaths nationwide. Although there has been substantial progress, especially with reduced mortality in nursing homes, increases are still occurring, and vaccine hesitancy gaps remain among certain groups.
It is significant and dangerous that, as the end of COVID-19 emergency measures is being considered, vaccination rates among the elderly and nursing home residents and staff are not universal, with only a few medical exceptions. Data show that they are now only in the 80 to low 90 percent range, with boosters below 65 percent for residents and below 30 percent for staff. With much delay, the federal government is finally requiring nursing home staff to get vaccinated (which is appropriate for those with no proof of prior infection). Normally, individual nursing homes mandating staff vaccinations would have caused staff departures, but a government-imposed mandate also applied to home care agencies and other competitors in the labor market lowers that risk. Nonetheless, staff booster rates still lag severely, and it would be reasonable for the federal government to incentivize staff to get boosters through modest cash awards, say $300. This modest spending would be a much more appropriate expenditure than the billions spent on direct care workers providing home care in the 2021 American Rescue Plan legislation (with no connection to COVID-19). The requirement in New York and California that visitors to nursing homes, most of whom are older adult children and relatives, must be vaccinated and boosted should be made national, through guidance from the Centers for Medicare & Medicaid Services. The continual testing rules of these states, however, seem excessively burdensome and unnecessary and an exception for those with proof of prior infection is appropriate.
This raises the natural question whether there should be a requirement for nursing home residents to be fully vaccinated against COVID-19, similar to other group living arrangements, like the armed forces and colleges, for example. This seems to be legal. Though the danger is that mandates create resistance and politicization. Political resistance is typically less significant among the elderly. Still, it would be inhumane to kick out current residents who refuse a vaccine, but because turnover is high in nursing homes, a mandate just for new residents would vaccinate all residents within a year or so. More aggressive, but culturally sensitive and effective education and persuasion efforts should be made also through pharmacies which have been somewhat effective at nudges. Perhaps this is a task for Medicare? The entire non-vaccinated elderly and disabled population could be notified that a vaccine appointment has been made for them and will be paid completely through their Part B or Part D benefits. Furthermore, COVID-19 vaccination rates of residents should play a major role in CMS nursing homes quality ratings.
We can be safer and more confident in our post-COVID lives if we aggressively address the safety of those most vulnerable. This can be done with attention and direction.
Mark J. Warshawsky is a Senior Fellow at the American Enterprise Institute. He is a former Deputy Commissioner for Retirement and Disability Policy at the Social Security Administration, and served as Vice-Chairman of the 2013 Long-term Care Commission.