America is heading toward a nursing home crisis: as the 80+ population surges, the number of nursing homes keeps shrinking—driven by staffing shortages, low wages, high turnover, immigration pressures, and looming Medicaid cuts. In this conversation, we sit down with Dr. Mark Aaron Unruh, Associate Professor of Population Health Sciences at Weill Cornell Medicine and a leading expert on the economics and policy of long-term care, whose research has informed the Senate Finance Committee, the Senate Special Committee on Aging, and the White House.

Transcript:

Jeffrey Snyder, Broadcast Retirement Network

Well, Dr. Unruh, it’s so great to see you. Thanks for joining us on the program this morning.

Dr. Mark Aaron Unruh, Weill Cornell Medicine

Thank you very much for having me.

Jeffrey Snyder, Broadcast Retirement Network

You know, this, it’s no, the audience members who watch the show on a regular basis and presumably read a lot in the national press, it should come as no surprise that we have an aging America. You know, there are more people now over 65 than at any time and like other countries, we have some challenges there. And I love that you and your colleagues wrote a piece about the potential shortages of nursing homes.

Give us the top line here. Are we, do we need to do some work here in America to account for these older Americans?

Dr. Mark Aaron Unruh, Weill Cornell Medicine

Yes, absolutely. So there are basically two concurrent trends happening which really weren’t put together until recently. We’ve known for a long time about the projections of our aging population.

Just as an example, the population age 80 and older is projected to increase by about 45% over the next decade. That’s an age that’s associated with increased risk of disabilities, increased need for assistance with activities, daily living and onset of dementia. At the same time, we’ve had a decrease in the supply of nursing home beds.

Just as an example of that, if you go back about a decade, there were about 900 more nursing homes in the US. There are currently about 14 and a half thousand now and there used to be about 15,400, 500 a decade ago. On top of that, we have additional challenges that are not just contributing to a decline in the number of nursing homes but the number of available beds.

So you can imagine with the COVID-19 pandemic, we heard a lot about this. There have been staffing challenges and those continue. So working in a nursing home, for example, as a certified nursing assistant is a very difficult job, both physically and emotionally.

The wages tend to be low. There’s a high occupational injury rate. It’s not surprising that turnover rates among those positions can be 100% annually or even higher in some facilities.

So when you put those two trends together, aging population and contracting nursing home supply, that leads to a very big problem. So as I mentioned earlier, with the aging population, there’s gonna be a greater prevalence of dementia, for example, and with the onset, with an increased prevalence of people with severe dementia, that’s going to increase the need for nursing home beds. There really isn’t an alternative for many people who need 24-hour care associated with the needs of cognitive decline once they do have severe dementia.

So that’s sort of what we’re looking at in the upcoming years.

Jeffrey Snyder, Broadcast Retirement Network

And so it sounds to me as a lay person here, it sounds like we need to start building, not we, but as a society, we need to maybe help prioritize building of these facilities to help for this growth in population. I mean, that seems like a necessary next step, or am I missing something?

Dr. Mark Aaron Unruh, Weill Cornell Medicine

That’s correct. But also we need to be able to staff those facilities. So right now, occupancy, as I mentioned earlier, there are challenges with staffing these facilities.

And about half of all nursing homes have limited their entries for new patients. Just, you know, you may, if you look up the number of nursing home beds in the U.S., that can be misleading. Those numbers represent the number of nursing home beds certified by states.

But let’s say if a nursing home has 150 certified beds, they may only actually be able to staff 100 of those beds. So there can be bottlenecks there. And this, so there are, the first place to start is staffing.

So, and there are some things working against the industry at this time. A large portion of direct care workers in nursing homes are immigrants. And the U.S.-born population that works in nursing homes has been declining pretty rapidly since the onset of the pandemic. However, the immigrant workforce in nursing homes has remained pretty steady. However, again, it’s difficult to attract enough workers to fully staff these nursing homes. Again, there are wage challenges.

So the average wage, I believe, is around $20 or so across the U.S. for a certified nursing assistant. And some of the bigger competitors for those workers are industries like fast food, for example. There’s, again, it’s very physically, emotionally demanding work.

And there’s little room for promotion and career advancement. There’s not a lot, tends to not be a lot of training opportunities for those workers. And all this leads to high turnover rates, difficulty recruiting, retaining individuals for those positions.

So that’s really where we need to start. But that leads into other issues. It leads, as I noted, into immigration policy.

So with the recent trends under the current administration, it’s going to mean fewer workers in these facilities, smaller pool of available workers in these facilities. Likewise, with looming Medicaid cuts. So the Big Beautiful Bill Act is projected to decrease Medicaid funding by about $1 trillion over the next decade.

The Medicaid tends to be the primary payer for people receiving long-term care in nursing homes. And Medicaid payments, on average, only cover about 80, 85% of the cost. So if you’re having cuts to Medicaid, that makes it difficult to increase wages and create other programs to recruit and retain workers in these facilities.

And all this too, oh, I’m sorry, go ahead.

Jeffrey Snyder, Broadcast Retirement Network

No, no, finish your thought. But I do have a follow-up question to that. Go ahead and finish your thoughts, sir.

Dr. Mark Aaron Unruh, Weill Cornell Medicine

Sure. And one thing we haven’t brought up, though, is with limited access to nursing home care for people who need it, this really increases the caregiving burden on families. That’s already a huge problem in the U.S. and creates not just physical challenges, logistical challenges, but also financial challenges and emotional challenges. Anyone who’s had someone in their family they’ve had to probably care to in these types of situations knows what I’m talking about.

Jeffrey Snyder, Broadcast Retirement Network

Yeah, that was gonna be my follow-up question. So who handles the spillover? So if we don’t have enough staff for the reasons you outlined, we can’t attract workers for those reasons.

So we can’t support all those beds. We’re gonna need more beds. So then it falls to the families.

That means those family members are gonna be taking care of loved ones. They may not be trained to do that, doctor. And also they may have jobs.

They may be professionals. They may have their own children or their spouse to care for.

Dr. Mark Aaron Unruh, Weill Cornell Medicine

Exactly, yes, yes. And they may not be able to provide adequate care. For example, people with complex medical needs or advanced dementia who need 24-hour care families typically aren’t able to provide that.

And it’s very expensive to try and bring in workers into your home to provide that additional care that they need. Many families just can’t afford that. So what this does is on top of increasing the burden on families it affects the whole healthcare system.

I think this is something people don’t realize. So if someone is hospitalized and they’re in need, so let me back up one moment. Nursing homes provide care to two populations.

The first population are those who are say recently hospitalized but they’re not quite well enough to go home and they need a few weeks of post-acute care. Basically this involves three or four weeks say of physical therapy, occupational therapy and maybe even speech therapy. And those days are typically covered by Medicare.

And Medicare has pretty generous payments that are profitable for nursing homes for post-acute care. The other population are those receiving long-term care. And that’s sort of the population we’ve been focusing on so far.

And individuals in need of long-term care the majority of those stays are paid by Medicaid. Maybe two-thirds of those days are covered by Medicaid. And that gets into the issues I was talking about before with payments and so on and covering the cost of care.

But when there’s a shortage of nursing home beds there may be a patient in the hospital who’s in need of post-acute care and they can’t find a bed or maybe someone whose condition has declined and they’re in need of placement for long-term care in a nursing home and you can’t find a bed for that individual either. This means that they have longer hospital stays, for example. And that’s taking up a bed that someone else may need for other care.

And this also affects hospital revenue and so on. So you can see where it really sort of creates a bottleneck.

Jeffrey Snyder, Broadcast Retirement Network

Yeah, I think it does. And I would have to imagine you mentioned I don’t want to get into the politics of it but immigration, I’m sure that you could refine the immigration policy in the country to be an incentive or incentivize people to come here to do this work, right? I mean, that’s, if they would look at their current situation and say, oh, well, I can come to the United States on some, again, I don’t know all the details about the different types of visas that are available but they can come here and participate in our system while contributing in terms of caring for loved ones.

Do you think this is something that, obviously you write about this, you work with your colleagues, are local state leaders and federal leaders aware of these challenges? And is this a high priority, I guess, is my question for them.

Dr. Mark Aaron Unruh, Weill Cornell Medicine

Many are aware of it. I don’t know how high of a priority it is, but also it affects different regions differently. So many areas have severe shortages, others less so, but eventually it’s going to affect almost all of us.

But your comment about a visa pathway would be very helpful. Other countries have tried that and there has been research showing that increased immigration helps increase the labor pull for these types of positions. And it’s also been associated with increased quality of care at nursing homes because they’re able to increase staffing levels with higher immigration.

So that is one potential pathway. That’s something that could be implemented with training programs and employer accountability to potentially mitigate some of these staffing shortages.

Jeffrey Snyder, Broadcast Retirement Network

Yeah, it’s a big challenge. And look, candidly, doctor, we’re all going to need long-term care at some point. I mean, you don’t get off this planet.

As we age, we’re going to need more healthcare and the healthcare expenses go up in the last five to 10 years of your life. We’re all going to need this. No one gets to escape this, right?

I mean, unless you have some kind of catastrophic illness or your life is shortened. But for the most part, we’re all going to face this circumstance.

Dr. Mark Aaron Unruh, Weill Cornell Medicine

Yeah, well, maybe as much as half of us are going to need post-acute or long-term care in a nursing home at some point in our life. So it’s an important topic. And as the population continues to age and the number of older adults increases, even if the number of nursing home beds remain constant where it is now, the supply won’t be anywhere near enough to meet demand.

Jeffrey Snyder, Broadcast Retirement Network

Yeah, it’s, look, I think this is, and we didn’t even talk about longevity because people are living longer. And the comment, the conversation about healthspan, you want to live longer, but you don’t want to live better. I think this is, I don’t pretend to prioritize things for the US Congress or anybody.

But I mean, I think to me, when I’m thinking about my own life, I want to make sure that I’m taken care of. Doctor, we’re going to have to leave it there. It’s a great piece.

Thanks for bringing it to our attention. And we look forward to having you back on the program again very soon, sir.

Dr. Mark Aaron Unruh, Weill Cornell Medicine

Great, and thank you again for having me.