This story from the Investigative Reporting Workshop was produced in collaboration with Eye on Ohio, the nonprofit, nonpartisan Ohio Center for Journalism. Please join Eye on Ohio’s free mailing list as this helps us provide more public-service reporting.
As Ohio grapples with the highest number of State Tested Nurse Aides (STNAs) shortages in the country and decades-long issues of pay and work conditions, legislation over nursing homes has become a lucrative battleground both nationally and in the state.
The industry’s primary trade group representing two-thirds of nursing homes has spent more than $30 million on lobbying to Congress since 2010. The state affiliate, Ohio Health Care Association (OHCA), and its related entities have contributed millions of dollars in recent years to political groups that have supported various campaigns, including Gov. Mike DeWine’s.
Unlike other states, Ohio legislators — not the state’s department of Medicaid — determine the funding formula for nursing homes.
Federal legislation from 1987 mandated only that nursing homes provide “sufficient staffing” of nursing assistants. Since then, some states, such as California and Maine, have gone beyond the federal requirement to implement industry-specific minimum wage laws or staff-per-patient ratios into state law. Other states, including Ohio and neighboring Michigan and Pennsylvania, solely refer to the federal rule and have nursing homes determine their own wages and workload for STNAs.
In general, states with higher wages and staffing ratio minimums have fewer staffing shortages, according to Loren Anthes, public policy fellow at the Medicaid Policy Center at The Center for Community Solutions in Cleveland. But the solution to the shortages is more complex than simply raising wages for nursing home workers, he said.
Anthes said systemic reform needs to happen as more Ohioans choose to receive care in their homes rather than at a specialized nursing facility, and as the state tries to incentivize nursing homes to get rid of empty beds. Ohio had the largest number of patients transition from nursing homes to community-based options in the nation in 2015, according to a 2020 journal article from Miami University’s Scripps Gerontology Center.
“We are much more institutional than we need to be,” Anthes said. “So not only do we have staffing problems, but we have a mandate for more staff that may not be needed because we have too many facilities and operators in the state generally.”
Ohio’s combination of low wages and no staffing ratios for STNAs while having more beds makes the Buckeye state unique, Anthes said.
But there’s no silver bullet to addressing Ohio’s STNA shortage, according to interviews with experts and stakeholders.
Pete Van Runkle, executive director of OHCA, said larger, complex issues such as the imbalance of available young workers to older Ohioans needing care and the nationwide labor shortage are partly to blame for the shortage.
Though it wouldn’t be an antidote, additional funding is needed for nursing homes and other long-term care facilities to address the STNA shortage, Van Runkle said. With Ohio’s budget and Medicaid reimbursement processes over, Van Runkle said nursing homes were looking for dollars from pandemic relief funds.
“Longer term, we really do have to look at Medicaid rates,” Van Runkle said. “Because this, as I said, is one-time money that is dedicated for COVID, but the workforce crisis is really something that’s been exacerbated by COVID, and it’s not going to go away when COVID is under control.”
Greg Lawson, a research fellow at The Buckeye Institute, a think-tank in Columbus, said the state should ensure that any readjustments of Medicaid reimbursement rates for nursing homes should specify how the money should be spent.
“One of the worst outcomes would be to just pour money into the system and not target it appropriately to meet the shortage question,” Lawson said.
Another potential solution to the STNA shortage would be to expand the pool of instructors for required courses for the position, Lawson said.
Federal law allows only registered nurses with at least two years’ experience, including at least one year in a nursing home, to teach. Lawson said allowing more people, including experienced STNAs, to become instructors could help prevent bottlenecking in that area.
Anthes said other systemic solutions to the STNA shortage include increasing home- and community-based options for residents, implementing quality incentive programs for facilities and increasing training for staff.
Facilities have been trying to address STNA shortages on a case-by-case basis with different tactics, including offering signing bonuses and an increase in pay, according to Anthony Caldwell, vice president of public affairs for the Service Employees International Union, whose members include nursing assistants.
But Caldwell said the increases in pay still “pales in comparison” to the worth of STNAs’ work, and their benefits remain “unimpressive.”
Activists and lobbyists who spoke with Eye on Ohio and the Investigative Reporting Workshop expressed frustration at the lack of legislative action surrounding Ohio nursing homes. Many said the industry’s influence via financial campaign contributions to legislators prevents what they consider pro-resident and pro-staff bills from being introduced.
Paula Mueller, founder and president of the nonprofit Elderly Advocates, said she’s tried to work with several legislators on bill ideas, but none has made it to the floor. She described the industry’s legislative influence as “well-orchestrated efforts, so it’s not so visible what’s going on.”
Most recently, the state Senate removed a proposed oversight program from DeWine that nursing homes criticized as excessive and unnecessary.
Mueller and other activists and lobbyists said that the few nursing home-focused bills were not intended to benefit residents or staff and that any attempts to keep the industry accountable, such as the current formula that partially funds facilities based on meeting certain standards, lack any teeth.
A proposed constitutional amendment is the latest effort from Ohioans trying to change STNAs’ work conditions across the state. A real estate agent in Cleveland’s proposed “Nursing Patients Bill of Rights,” which includes minimal staffing levels, recently became one step closer to being put on the ballot next year and avoiding hurdles in the legislature.
Anthes said that attempts to improve nursing homes and keep the industry accountable on the state level are necessary because nursing homes provide vital care to residents and their families.
“Because they’re so important, you can’t just let them off the hook,” Anthes said. “Because how many Ohioans are facing situations with parents that are aging? And how are they going to know what’s a quality facility or not?”