Introduction

There has been sustained attention on nursing homes in the wake of COVID-19, from the initial widespread outbreak at a facility in Washington State to the disproportionate number of cases and deaths among residents and staff nationally throughout the pandemic. Nursing home residents include 1.2 million seniors and nonelderly people with disabilities living in over 15,000 facilities. These residents and the 3 million people who work in skilled nursing or residential care facilities are at increased risk of infection due to the highly transmissible nature of the coronavirus, combined with the congregate nature of facility settings and the close contact that many workers have with patients. If infected, many residents are at increased risk of adverse health outcomes and death from COVID-19, due to old age and/or underlying chronic health conditions. Over 40% of all COVID-19 deaths have been residents or staff of long-term care facilities, with even higher numbers in some states. At the pandemic’s outset, nursing home oversight and response was concentrated at the state level, which led to different protocols across states and facilities, with little federal involvement and substantial shortages of personal protective equipment and coronavirus tests.

As a result of the pandemic’s impact, policymakers, residents, staff, and others have raised questions about whether there has been sufficient federal and state oversight of and guidance for nursing homes, and CMS has released a series of guidance and other policy actions. The Social Security Act authorizes the Health and Human Services (HHS) Secretary to establish requirements relating to nursing home residents’ health, safety and well-being as conditions for facilities to receive payment from the Medicare and Medicaid programs. Nursing homes can be certified as Medicare skilled nursing facilities (SNFs)¹  and/or Medicaid nursing facilities (NFs).²  Medicare is the primary payer for about 12 percent of nursing home residents, with coverage limited to short-term stays for skilled nursing care or rehabilitation. Medicaid is the primary payer for 62 percent of nursing home residents, covering both short-term skilled nursing care and rehabilitation, as well as long-term care. This brief answers key questions about nursing home oversight and explains how federal policy has changed in light of COVID-19.

1.  How are the federal requirements for nursing home oversight enforced?

Certification of nursing home compliance with federal Medicare and/or Medicaid requirements generally is performed by states through regular inspections known as surveys.³  States receive 75% federal matching funds for Medicaid nursing facility survey and certification activities,⁴  while Medicare SNF survey and certification activities are funded by a discretionary appropriation. Appendix 1 explains the survey process. States also must investigate complaints of facility violations of federal requirements⁵  and allegations of abuse, neglect, and misappropriation of resident property by nurse aides or other facility service providers⁶  and conduct periodic educational programs for facility staff and residents about current regulations, policies, and procedures.⁷ 

The penalties for facilities found to be out of compliance with federal requirements vary depending on whether the deficiency is determined to immediately jeopardize residents’ health or safety.⁸  For deficiencies that result in immediate jeopardy, a facility is subject to the appointment of temporary management to oversee operations while deficiencies are corrected or termination from the Medicare and/or Medicaid programs with the safe and orderly transition of residents to another facility or community setting.⁹  However, a facility may continue to receive Medicare and/or Medicaid payments for up to six months after a deficiency finding, if the state finds that this alternative is more appropriate than program termination. In these instances, the facility must agree to repay Medicare funds, and the state must agree to repay federal Medicaid funds, if corrective action is not taken according to a Secretary-approved plan and timetable. For deficiencies that do not result in immediate jeopardy, a facility may be allowed up to six months to correct deficiencies. A facility that does not come into substantial compliance within three months is subject to denial of Medicare and/or Medicaid payment for all individuals admitted after the deficiency finding date. A facility that is not in substantial compliance within six months is subject to Medicare program termination and discontinuance of Medicaid federal financial participation.

Civil money penalties (CMPs) can be imposed for the number of days a facility is not in substantial compliance or for each instance that a facility is not in substantial compliance.¹⁰  CMPs can range from $6,525 to $21,393 for deficiencies constituting immediate jeopardy, and from $107 to $6,417 for deficiencies that do not constitute immediate jeopardy but either caused actual harm or did not cause actual harm but have the potential for more than minimal harm. Per instance CMPs range from $2,140 to $21,393. A portion of CMP funds collected are returned to states and can be used for activities that protect or improve care quality or resident quality of life as approved by CMS, such as supporting and protecting residents during facility closures, relocating residents, supporting resident and family councils and other consumer involvement, facility improvement initiatives such as staff and surveyor training or technical assistance for quality assurance and performance improvement programs, or developing and maintaining temporary manager capability such as recruitment, training, or system infrastructure expenses.

Additional remedies apply to facilities with patterns of deficiencies over time. A facility that is found to provide substandard care quality on three consecutive standard surveys is subject to denial of Medicare and Medicaid payments for all new admissions or entirely and is subject to state monitoring until the facility demonstrates that it has regained and will remain in substantial compliance.¹¹  CMS and/or the state also may direct staff in-service training for facilities with patterns of deficiencies.

2.  How have the federal nursing home requirements evolved over time?

Prior to the late 1960s, nursing homes were “essentially unregulated in most states,” and care quality was generally considered to be poor.¹²  The creation of Medicare and Medicaid in 1965 led to greater federal involvement in nursing home regulation with the establishment of federal criteria to certify facilities. However, concern about care quality and inadequate enforcement continued through the 1970s and 1980s, leading to the appointment of an Institute of Medicine (IOM) committee to recommend changes. The IOM recommendations included incorporating resident assessment, care quality, quality of life, and residents’ rights in federal conditions of participation and making both regulatory requirements and the survey and certification process more “resident-centered and outcome-oriented,” with a shift in emphasis “from facility capability to facility performance.”¹³  The IOM report also recommended increased federal funding and oversight of state survey agencies and establishing intermediate sanctions short of program termination and facility closure to enforce compliance. Appendix 2 contains additional background about the evolution of federal nursing home oversight.

The IOM recommendations led to changes adopted in the 1987 Nursing Home Reform Act, which established Medicare SNF and Medicaid NF requirements in three main areas: service provision, residents’ rights, and administration and other matters (Appendix Table 1). The Nursing Home Reform Act strengthened federal standards, inspections, and enforcement provisions; merged Medicare and Medicaid standards; required comprehensive resident assessments; set minimal licensed nursing staff requirements; and required inspections to focus on care outcomes.¹⁴  Service provision requirements are related to quality of life, care plans, resident assessment, services and activities, nurse aide training, physician supervision and clinical records, social services, and nurse staffing information.¹⁵  Facilities must protect and promote specific residents’ rights including free choice, freedom from restraints, privacy, confidentiality, accommodation of needs, grievances, participation in resident and family groups and other activities, examination of survey results, and refusal of certain transfers. Additional requirements govern the use of psychopharmacologic drugs, advance directives, access and visitation, equal access to quality care, admissions, and protection of resident funds. Administration requirements include licensing and life safety code, sanitary and infection control and physical environment standards.

To help address continuing quality concerns, the 2010 Affordable Care Act (ACA) included some additional reforms. The Nursing Home Transparency and Improvement Act, adopted as part of the ACA, sought to address complex ownership, management, and financing structures that inhibited regulators’ ability to hold providers accountable for compliance with federal requirements. The ACA also incorporated the Elder Justice Act and the Patient Safety and Abuse Prevention Act, which include provisions to protect long-term care recipients from abuse and other crimes.

The 2016 nursing home regulations issued by the Obama Administration were the first comprehensive update in 25 years. The original consolidated Medicare and Medicaid facility participation requirements were issued in 1989, following the Nursing Home Reform Act, and revised in 1991. The 2016 regulations sought to account for ensuing innovations in resident care and quality assessment and an increasingly diverse and clinically complex resident population.¹⁶  New requirements added by the 2016 regulations most relevant to issues raised by COVID-19 include those related to infection control, facility assessment, and emergency preparedness (Box 1). The 2016 regulations also revised provisions related to resident rights, adopting a greater emphasis on person-centered care; reporting of abuse and neglect; and transfer and discharge rights. Additionally, the 2016 regulations added a new section on behavioral health services, adopted a competency requirement for determining staffing sufficiency and new staff training program requirements, and implemented ACA requirements for facility quality assurance and performance improvement programs¹⁷  and compliance and ethics programs.¹⁸  The regulations were implemented in three phases from 2016 through 2019.

In July 2019, the Trump Administration proposed a number of changes to the 2016 regulations, which it said would increase provider flexibility and reduce regulatory burden. The proposed changes, which are still pending, include:

• Removing the existing requirement that the infection preventionist work at the facility at least part-time or have frequent contact with infection prevention and control program staff and instead requiring that the infection preventionist has “sufficient time” at facility to meet program objectives; and
• Modifying current provisions governing the use of psychotropic medications, the grievance process, the timeframe for retaining staffing data, the quality assurance and performance improvement program, and the compliance and ethics program, among other areas.

Also in July 2019, the Trump Administration issued a final regulation that eliminated the existing ban on pre-dispute arbitration agreements.

3.  What was the state of nursing home quality before and during COVID-19?

Infection control deficiencies were widespread and persistent in nursing homes prior to the COVID-19 pandemic, according to a May 2020 GAO report.²⁰  The GAO found that “infection prevention and control deficiencies were the most common type of deficiency cited in surveyed nursing homes, with most nursing homes having an infection prevention and control deficiency cited in one or more years from 2013 through 2017 (13,299 nursing homes, or 82 percent of all surveyed homes).” All states had facilities with infection prevention and control deficiencies cited in multiple consecutive years, indicating “persistent problems.” These deficiencies include staff failing to regularly use proper hand hygiene or failing to implement preventive measures to control infection spread during an outbreak, such as isolating sick residents and using masks and other personal protective equipment (PPE). GAO also found that nearly all infection prevention and control deficiencies were classified by surveyors as not severe, meaning the surveyor determined that residents were not harmed, and implemented enforcement actions for these deficiencies were typically rare. GAO plans future reports to examine CMS guidance and oversight of infection control more broadly as well as CMS’s response to COVID-19.

In regular surveys conducted from January 2019 through March 2020, nearly half of facilities received an infection control deficiency (Figure 1). Most facilities (80%) received a deficiency related to resident quality of life or care, and 37% received an abuse/neglect/exploitation deficiency (Figure 1). Just under 20% of facilities received a CMP, with the average amount just over $25,000 (Figure 1). During this same time period, 62% of facilities had substantiated complaints regarding violations of federal requirements, and 39% of facilities had incidents with alleged or suspected resident abuse, neglect, or misappropriation of property (Figure 1).

In response to COVID-19, CMS suspended state survey activities in March 2020, except for those related to infection control and immediate jeopardy. Nearly all nursing homes have received these targeted surveys since March 4, 2020, with preliminary inspection reports revealing only a small share with deficiencies (Figure 2). Just 13% of the nearly 6,000 facilities surveyed between March 4 and May 30, 2020 were cited as deficient in meeting any federal requirements. Though nursing homes across the country have experienced high rates of COVID-19 cases and deaths, the data does not point to quality deficiencies as a reason for this occurrence.

4.  How has nursing home oversight changed in light of COVID-19?

As the number of COVID-19 cases and deaths in nursing homes increased, CMS has issued guidance about how facilities should respond to the pandemic (Figure 3). A February 2020 informational bulletin advised health care facilities to review the Centers for Disease Control (CDC) COVID-19 advisory and recommendations as well as their own infection control policies. As noted above, CMS suspended state survey activities in March 2020, except for those related to infection control and immediate jeopardy. That same month, CMS infection control and prevention guidance advised facilities to screen visitors and staff and about when to transfer residents to and accept those discharged from hospitals. CMS also required facilities to restrict all visitors except for compassionate care circumstances and cancel all communal dining and group activities, released guidance allowing facilities to perform COVID-19 tests, and issued a number of Section 1135 blanket waivers to help facilities’ emergency response. In April 2020, CMS issued guidance directing facilities to screen all staff, residents, and visitors for symptoms, ensure staff use PPE “to the extent available,” and designate separate staff and facilities or units for COVID-19 patients.

In April 2020, CMS announced the formation of an independent commission to conduct a comprehensive assessment of facility response to COVID-19. The commission is expected to make recommendations to protect residents from COVID-19 and improve care delivery responsiveness; strengthen efforts to rapidly identify and mitigate infectious disease transmission in nursing homes; and enhance strategies to improve compliance with infection control policies. The commission also is charged with identifying approaches to better use data to enable federal, state, and local entities to address the current spread of COVID-19 within facilities, analyze the impact of efforts to stop or contain the virus within facilities, and identify best practices to address COVID-19 that CMS or states could adopt. Commission members are to include residents, families, resident/patient advocates, industry experts, clinicians, medical ethicists, administrators, academics, infection control and prevention professionals, state and local authorities, and other experts. Twenty-five Commission members were announced in June 2020, and a final report is expected in fall 2020.

As of May 2020, facilities must report COVID-19 data to the CDC and provide information to residents and their families. Prior to this interim final rule, facilities were not required to report infectious disease information to the CDC, though they typically report to state and/or local health departments. The lack of centralized data contributed to difficulty in tracking disease spread and coordinating dissemination of personal protective equipment and testing supplies. The new rule requires weekly reporting of suspected and confirmed infections among residents and staff including residents previously treated for COVID-19; total deaths and COVID-19 deaths among residents and staff; PPE and hand hygiene supplies in the facility; ventilator capacity and supplies in the facility; resident beds and census; access to COVID-19 testing while a resident is in the facility; staffing shortages; and other information specified by the Secretary.

CMS is publicly reporting the data, and recently announced additional actions based on the data. In July 2020, CMS sent “Task Force Strike Teams” of clinicians and public health officials to 18 nursing homes in six states experiencing an increase in COVID-19 cases. The Teams are focused on determining immediate actions and needed resources to reduce virus spread. In late July 2020, CMS also announced that it would send a weekly list of nursing homes with an increase in cases to states.

The new rule also requires facilities to inform residents, their representatives, and families of confirmed or suspected COVID-19 cases among residents and staff by 5 pm the next calendar day following a single confirmed case or three or more residents or staff with new onset of respiratory symptoms within 72 hours of each other. Facilities also must provide cumulative updates at least weekly by 5 pm the next calendar day following each subsequent occurrence of confirmed infection or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other. Facilities must include information on mitigating actions implemented to prevent or reduce the risk of transmission including whether normal operations will be altered such as restrictions or limitations on visits or group activities. Facilities cannot release personally identifiable information and can communicate through paper notices, a listserv, a website post or recorded phone messages.

In May 2020, CMS issued nursing home reopening recommendations and an informational toolkit with best practices for states to mitigate COVID-19 in nursing homes. The reopening guidance sets out criteria for relaxing restrictions using a phased approach and mitigating the risk of resurgence, including case status in the community, case status in the facility, adequate staffing, access to adequate testing, universal source control (masks, social distancing, and hand washing for visitors), adequate access to PPE for staff, and local hospital capacity. The guidance also includes considerations for allowing visitors and services and for restarting routine state survey activities in each phase. Additionally, quality improvement organizations (QIOs) under contract with CMS are providing technical assistance with a focus on about 3,000 low performing facilities with a history of infection control issues to help identify problems, create and implement an action plan, and monitor compliance. For example, QIOs train staff on proper PPE use, appropriate resident cohorting, and safe resident transfers. States also can request QIO technical assistance targeted to facilities that have experienced an outbreak.

In June 2020, CMS issued additional guidance to states on COVID-19 survey activities and enhanced enforcement for infection control deficiencies. CMS noted that focused infection control surveys pursuant to the March 2020 guidance had been completed in 53 percent of facilities, with wide state variation. As a result, states that have not completed all of these surveys by July 31, 2020 must submit a corrective action plan outlining their strategy to complete these surveys within 30 days. If all surveys still are not complete after the 30-day period, states’ CARES Act FY 2021 allocation may be reduced by up to 10%. Subsequent 30-day extensions could result in additional reductions up to 5%, with funding redistributed to states that have completed their surveys. The CARES Act provided $100 million for nursing home inspections focused on those with COVID-19 community spread from FY 2021 through FY 2023, $81 million of which will be available to state survey agencies. This represents a 6% annual increase in the nursing home survey and certification budget, which had remained at $397 million annually since October 2014. CARES funds may be used for state surveys, strike teams, enhanced surveillance or monitoring of nursing homes, or other state-specific interventions. The June 2020 guidance also establishes enhanced enforcement remedies for infection control deficiencies including directed plans of correction, discretionary denial of payment for new admissions, and CMPs.

The June 2020 guidance also announced three additional survey requirements: (1) states must perform on-site surveys of nursing homes with previous COVID-19 outbreaks by July 1, 2020; (2) states must perform on-site surveys within three to five days of identification of any nursing homes with three or more new suspected or confirmed cases since the last CDC COVID-19 report or one confirmed resident case in a facility that previously was COVID-free; and (3) starting in FY 2021, states must perform annual focused infection control surveys of 20 percent of facilities. States could forfeit 5% of their annual CARES Act allocation for failing to perform these activities.

The June 2020 guidance also authorizes states to expand survey activities to include more routine surveys once a state has entered phase 3 of the nursing home reopening guidance or earlier at state discretion. The expanded activities include complaint investigations that are not immediate jeopardy, revisit surveys to any facility with a removed immediate jeopardy finding but that is still out of compliance, special focus facility and special focus facility candidate recertification surveys, and nursing home and intermediate care facility for individuals with intellectual and developmental disabilities recertification surveys greater than 15 months. When expanding survey activities, states should prioritize facilities with a history or allegations of noncompliance regarding abuse or neglect, infection control, violations of transfer or discharge requirements, insufficient staffing or competency, or other care quality issues such as falls or pressure ulcers.

In late July 2020, CMS began requiring, rather than recommending, that all staff be tested weekly in nursing homes in states with a 5% or greater positivity rate. HHS also is distributing rapid diagnostic tests to nursing homes in COVID-19 hotspots through a one-time procurement to facilitate on-site testing of residents and staff. CMS and the CDC are offering COVID-19 training to nursing homes, which includes cohorting strategies and using telehealth to mitigate virus spread.

5.  What are the key challenges for nursing homes as the pandemic continues?

As the pandemic continues, state survey agencies may face issues related to funding, capacity, and data. CMS will withhold CARES funds from state survey agencies that do not timely complete inspections, but these penalties may be too blunt for agencies whose lack of compliance stems from insufficient funding in the first place. As noted above, prior to the new CARES Act funds, the survey and certification budget had remained flat since 2014. It remains to be seen whether these new funds will be sufficient for state agencies to perform regular surveys as well as increased oversight in the foreseeable future resulting from the pandemic. While facilities are now reporting COVID-19 cases and deaths to CMS, these data are not cumulative prior to May 8, 2020, and it will be important for both state survey agencies and CMS to continue to monitor data and adjust policy guidance and facility oversight as needed.

Nursing facilities also face a number of challenges in their continued pandemic response. Nearly $5 billion in federal provider relief funds has been allocated to nursing facilities to cover health care related expenses or lost revenues attributed to coronavirus. On July 22, 2020, HHS announced that an additional $5 billion from the provider relief fund is being allocated to Medicare-certified long-term care facilities and state veterans homes. These funds may be used to hire additional staff, implement infection control “mentorship” programs with subject matter experts, increase testing, and provide additional services, such as technology so residents can connect with their families if they are not able to visit. As of June 28, 2020, nearly one in three nursing homes nationally report a shortage of staff and/or PPE. Despite federal legislation generally requiring insurers to cover coronavirus testing without cost-sharing, recent federal guidance concludes that insurers do not have to cover coronavirus “testing conducted to screen for general workplace health and safety (such as employee “return to work” programs).” This leaves open the question about who will pay for regular tests needed for facility staff to safely work during the pandemic. It also remains to be seen whether facilities will be able to maintain adequate staffing levels as the pandemic continues. CMS has lifted its emergency waiver of the staffing data submission requirement, and facilities must submit regular staffing data for April through June 2020 by August 14, 2020. Facilities also may be under financial strain due to lower occupancy levels as a result of the pandemic.

Conclusion

While the data and experience to date do not show a direct link between nursing home quality and COVID-19 cases, the pandemic has brought renewed attention to issues of nursing home quality and oversight at the federal and state levels. Nursing home quality concerns have existed for decades. With the current focus on challenges facing nursing homes and state survey agencies as they respond to the pandemic, policymakers may revisit whether federal Medicare and Medicaid requirements should be adjusted to improve oversight and whether additional funding is needed to support providers and agencies to ensure sufficient capacity and resources. These issues are likely to continue to be the subject of policy discussion and debate as long-term care coronavirus cases, particularly in “hotspot states” with wider community transmission continue to rise. While most nursing facilities are Medicare-certified, a small number (315 or 2%) are only Medicaid-certified and therefore appear ineligible for a share of the additional provider relief funds announced on July 22.

More broadly, seniors and people with disabilities who receive long-term services and supports in other settings, such as assisted living facilities, intermediate care facilities for people with intellectual/developmental disabilities, institutions for “mental disease,” and group homes, also are at increased risk of serious illness if infected with coronavirus based on older age and/or chronic health conditions. Unlike nursing homes, other long-term care congregate settings are primarily regulated by states, leading to greater variation in quality protections and lack of standardized reporting about coronavirus cases, deaths, staffing, supplies, and other data necessary to understand and respond to the pandemic and understand its full impact on all people who receive long-term care services and the staff who provide them.

Appendix 1: Nursing Home Survey and Certification Process

A facility is subject to a standard survey, without advance notice, at least once every 15 months.²¹  If found to have provided substandard care quality,²²  a facility is subject to an extended survey within two weeks of the standard survey.²³  In addition, states may conduct special surveys within two months of any change in facility ownership, administration, management, or nursing director to determine whether care quality has declined as a result of the change.²⁴  The Secretary also can conduct special surveys when the Secretary has reason to question facility compliance with federal requirements.²⁵  Standard surveys include a case-mix stratified sample of residents.²⁶  Extended surveys review and identify facility policies and procedures that produced substandard care quality, expand the sample size of resident assessments reviewed, and review staffing, in-service training, and if appropriate, consultant contracts.²⁷ 

Facility surveys are conducted by a multi-disciplinary team using a protocol developed by the Secretary.²⁸  The survey team must include a registered nurse and may include physicians, physician assistants, nurse practitioners, physical, speech, or occupational therapists, dieticians, sanitarians, engineers, licensed practical nurses, social workers, or other professionals.²⁹  The survey team cannot include anyone who has served as staff or a consultant to the facility in the prior two years or who has a personal or familial financial interest in the facility.³⁰ 

Survey and certification information, including statements of deficiencies, must be made publicly available by states and the Secretary within 14 days after the facility is notified.³¹  States submit this information, including any enforcement actions, to the Secretary on the same day that the facility is notified, and the Secretary uses this information to update the federal Nursing Home Compare website at least quarterly.³²  The website must include facility staffing data, including resident census data and hours of care provided per resident per day and information on staffing turnover and tenure; links to state survey and certification programs, inspection reports, and facility plans of correction or report responses; information on how to file a complaint with the state survey and certification program and the state long-term-care ombuds program; summary information on the number, type, severity, and outcome of substantiated complaints; the number of adjudicated instances of criminal violations by the facility or its employees committed within the facility regarding abuse, neglect, exploitation, criminal sexual abuse or other violations resulting in serious bodily injury; and CMPs levied against the facility, its employees, contractors, and other agents. States also must notify the state long-term care ombudsman of any findings of noncompliance or adverse actions taken against facilities.

Appendix 2: History of Federal Nursing Home Requirements

After the creation of the Medicare and Medicaid programs, it soon became clear that “[s]trict enforcement of federal standards would have barred most nursing homes from participating in the Medicare program”³³  in the mid-1960s, and certification of nursing homes to participate in Medicaid was left to the states.³⁴  After increased congressional and media attention to substandard facility conditions and lax government oversight, revised federal regulations certifying facilities to participate in Medicare and Medicaid were established in 1974. Continued concern about care quality and inadequate enforcement led to new proposed federal regulations issued in 1980 by the Carter Administration. However, the nursing home industry objected to the new regulations’ projected costs, and the regulations were rescinded by the Reagan Administration. In turn, the Reagan Administration’s subsequent proposal, which would have deleted or relaxed many existing standards, was set aside after opposition from consumer advocates, states, Congress, and providers. The impasse led to the appointment of an Institute of Medicine (IOM) committee to recommend changes.

The 1986 IOM committee report contained numerous recommendations to enhance nursing home care quality and resident quality of life by improving nursing home regulation.³⁵  While the IOM committee credited the 1974 regulations with contributing to better care quality, it noted “substantial room for improvement” due to weaknesses in the regulations and uneven administration and enforcement by states.³⁶  At the time of the IOM study, “there [was] broad consensus that government regulation of nursing homes, as it now functions, is not satisfactory because it allows too many substandard nursing homes to continue in operation.” Concerns included “neglect and abuse leading to premature death, permanent injury, increased disability, and unnecessary fear and suffering on the part of residents,” poor quality of life and lack of autonomy, and poor quality medical and nursing care.³⁷  The IOM committee emphasized that government regulation of nursing homes is warranted due to residents’ “large array of physical, functional, and mental disabilities,” limited opportunities for transfer among facilities, and inability to pay for care out-of-pocket.

Although the IOM recommendations led to changes adopted in the 1987 Nursing Home Reform Act, concerns about poor care quality and inadequate enforcement of federal standards continued. Between 1997 and 2010, the Government Accountability Office (GAO) issued more than 20 reports finding substandard care in many nursing homes; understatement of serious deficiencies by state surveyors; unenforced sanctions for harming residents; facilities cycling in and out of compliance; and inconsistent and ineffective federal oversight.³⁸  During the same period, the HHS Office of Inspector General issued reports critical of facility compliance and state and federal enforcement.³⁹  Recurring concerns include staffing levels, abuse and neglect, unmet resident needs, care quality, staff training and competency, and lack of integration between medical care and other services.⁴⁰ 

1. A Medicare skilled nursing facility (SNF) is an institution or distinct part that is primarily engaged in providing skilled nursing care and related services or rehabilitation services. 42 U.S.C § 1395i-3 (a). ↩︎
2. A Medicaid nursing facility (NF) is an institution or distinct part that is primarily engaged in providing skilled nursing care and related services, rehabilitation services, or health-related care and services on a regular basis to individuals who because of their mental or physical condition require institutional care and services above the level of room and board. 42 U.S.C. § 1396r (a). In addition, SNFs and NFs cannot be primarily for the care or treatment of mental illnesses and must have a transfer agreement in effect with one or more hospitals. Id.; 42 U.S.C. § 1395i-3 (a). ↩︎
3. The exception is state facilities, which are certified by the Secretary. 42 U.S.C § § 1395i-3 (g); 1396r (g). ↩︎
4. 42 U.S.C. § 1396b (a)(2)(D). ↩︎
5. 42 U.S.C. §§ 1395i-3 (g)(4); 1396r (g)(4). ↩︎
6. States must maintain a registry of abuse, neglect, and misappropriation findings. 42 U.S.C. §§ 1395i-3 (g)(1)(C); 1396r (g)(1)(C). ↩︎
7. 42 U.S.C. §§ 1395i-3 (g)(1)(B); 1396r (g)(1)(B). ↩︎
8. For Medicare SNFs, states recommend penalties to be imposed by the Secretary based on survey results, and the Secretary also can independently impose penalties based on survey results or other findings. 42 U.S.C. § 1395i-3 (h). For Medicaid NFs, state law must include the specified penalties, which are imposed by states based on survey results or other findings. 42 U.S.C. § 1396r (h). ↩︎
9. The facility must pay the temporary manager’s salary. If the immediate jeopardy is also substandard care quality, the state must notify each resident’s attending physician and the state facility administrator licensing board. 42 U.S.C. § § 1395i-3 (g)(5)(B), (C); 1396r (g)(5)(B),(C). ↩︎
10. A CMP can be reduced in two ways, though only one penalty reduction can be applied. A CMP is reduced by 35 percent if a facility waives its right to a hearing to dispute the penalty. Or, a CMP may be reduced by 50 percent if a facility self reports and promptly corrects a deficiency, except that CMPs for repeat deficiencies within the prior year and for deficiencies found to result in a pattern of harm or widespread harm, immediately jeopardy to resident health or safety or resident death may not be reduced. 42 U.S.C. § § 1395i-3 (h)(2)(B)(ii); 1396r (h)(3)(C)(ii). ↩︎
11. 42 U.S.C. § § 1395i-3 (g)(4); 1396r (g)(4). ↩︎
12. Institute of Medicine 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press at 5. https://doi.org/10.17226/646. ↩︎
13. Id. at 79. ↩︎
14. KFF, Key Issues in Long-Term Services and Supports Quality (Oct 2017), https://modern.kff.org/medicaid/issue-brief/key-issues-in-long-term-services-and-supports-quality/. ↩︎
15. Medicaid NFs are subject to additional preadmission screening and resident review (PASRR) requirements to ensure that individuals with serious mental illness or intellectual disabilities require a nursing facility level of services and whether any specialized services are required. PASRR reviews are conducted by the state mental health or developmental disability authorities upon admission and when there is a significant change in a resident’s condition. 42 U.S.C. § 1396r (e)(7). ↩︎
16. 81 Fed. Reg. 68688 (Oct. 4, 2016), https://www.govinfo.gov/content/pkg/FR-2016-10-04/pdf/2016-23503.pdf. ↩︎
17. 42 C.F.R. § 483.75. ↩︎
18. 42 C.F.R. § 483.85. ↩︎
19. 42 C.F.R. § 483.73. ↩︎
20. U.S. Gov’t Accountability Office, Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic (May 20, 2020), https://www.gao.gov/assets/710/707069.pdf. ↩︎
21. There must be a 12-month statewide average interval between standard surveys 42 U.S.C. § § 1395i-3 (g)(2)(A)(i), (iii)(I); 1396r (g)(2)(A)(i), (iii)(l). The Secretary conducts surveys of a representative sample of facilities in each state, within two months of state surveys, to validate state findings. If the Secretary finds that a state’s surveys were inadequate, the state is subject to sanctions, including a correction plan, training, and/or technical assistance for SNF survey inadequacies, and a reduction in federal matching funds for Medicaid administrative costs for a pattern of failure to identify deficiencies and training for NF survey deficiencies. 42 U.S.C. § § 1396r (g)(3)(C) 1395i-3 (g)(3)(C); 42 C.F.R. § 488.320. ↩︎
22. Substandard care quality includes one or more deficiencies in the following areas: treating residents with dignity and respect and in a manner that promotes quality of life; providing equal access to quality care regardless of condition severity or payment source; ensuring residents can freely exercise rights; not imposing physical or chemical restraints for discipline or convenience; reasonably accommodating resident needs and preferences in receiving services; allowing married residents to share a room with spouse; allowing residents to have roommate of their choice; providing written notice of change of room or roommate; allowing residents to choose activities, schedules, health care and providers; allowing residents to make choices about aspects of facility life significant to the resident; allowing residents to participate in community activities; allowing resident and family groups; allowing family or representatives of the resident to meet in the facility with other residents’ family or representatives; and providing a safe, clean, comfortable, and homelike environment. 42 C.F.R. § 488.301. ↩︎
23. 42 U.S.C. § § 1395i-3 (g)(2)(B); 1396r (g)(2)(B). ↩︎
24. 42 U.S.C. § § 1395i-3 (g)(2)(A)(iii)(II); 1396r (g)(2)(A)(iii)(ll). ↩︎
25. 42 U.S.C. § § 1395i-3 (g)(3); 1396r (g)(3). ↩︎
26. 42 U.S.C. § § 1395i-3 (g)(2)(A)(ii); 1396r (g)(2)(A)(ii). ↩︎
27. 42 U.S.C. § § 1395i-3 (g)(2)(B)(iii); 1396r (g)(2)(B)(iii). ↩︎
28. The Secretary also is responsible for providing survey team training. 42 U.S.C. § § 1395i-3 (g)(2)(C), (E)(iii); 1396r (g)(2)(C) (E)(iii). ↩︎
29. 42 C.F.R. § 488.314 (a)(2). ↩︎
30. 42 U.S.C. § § 1395i-3 (g)(2)(E)(i), (ii); 1396r (g)(2)(E)(i), (ii). ↩︎
31. 42 U.S.C. § § 1395i-3 (g)(5)(A); 1396r (g)(5)(A). ↩︎
32. 42 U.S.C. § § 1395i-3 (g)(5)(E); 1396r (g)(5)(E). ↩︎
33. Institute of Medicine 1986. Improving the Quality of Care in Nursing Homes. Washington, DC: The National Academies Press at 147. https://doi.org/10.17226/646. ↩︎
34. Id. at 242. ↩︎
35. See generally Id. ↩︎
36. Id. at 6. ↩︎
37. Id. at 3-4. ↩︎
38. KFF, Implementation of Affordable Care Act Provisions to Improve Nursing Home Transparency, Care Quality, and Abuse Prevention (Jan. 2013), https://modern.kff.org/medicaid/report/implementation-of-affordable-care-act-provisions-to-improve-nursing-home-transparency-care-quality-and-abuse-prevention/. ↩︎
39. Id. ↩︎
40. KFF, Key Issues in Long-Term Services and Supports Quality (Oct 2017), https://modern.kff.org/medicaid/issue-brief/key-issues-in-long-term-services-and-supports-quality/. ↩︎

The United States remains among the countries most severely impacted by the coronavirus pandemic, with reported COVID-19 cases rising again in many states. While much recent research and media reporting on the pandemic response has focused on the availability of hospital beds and medical equipment, there is also concern that the availability of medical personnel capable of providing intensive care could be a limiting factor in the care of COVID-19 patients. This is a particular challenge as cases and hospitalizations surge in hotspots across the country.

Using recent data from the National Plan and Provider Enumeration System (NPPES) National Provider Identifier (NPI) Registry, this Data Note reports baseline estimates of the number of active critical care physicians and nurses in each state relative to state population.

Background

To date, much of the federal and state-level response to the COVID-19 pandemic in the United States has focused on the availability of hospital resources such as funding, beds, and personal protective equipment.¹  However, some experts have signaled that personnel are also in short supply. Alarmingly, the Society for Critical Care Medicine (SCCM) reported that the number of providers trained in intensive care unit (ICU) care and mechanical ventilation could be a limiting factor in the care of COVID-19 patients, and has recommended that the pandemic response should place greater emphasis on increasing the number of available critical care professionals.² 

However, quantifying the number of critical care providers in the U.S. has historically been difficult. On the one hand, some professional societies have argued that only “intensivist” physicians who have completed a formal fellowship in critical care medicine should lead critical care teams, and some research suggests that this may improve clinical outcomes in the ICU setting.³  On the other hand, many providers without formal critical care training regularly care for critically ill ICU patients, including substantial numbers of hospitalists, pulmonologists, and anesthesiologists. The issue is further complicated by variability in the proportion of duty hours that individual providers spend in the intensive care setting. Researchers writing in 2015 noted that, “our current supply of full-time intensivists is very low, as the vast majority of adult, board-certified intensivists are really part-time practitioners based in pulmonary medicine, operating rooms (surgeons/anesthesiologists), or emergency medicine”.⁴ 

Consequently, prior estimates have reflected these limitations. For example, an early landmark study by the Committee on Manpower for Pulmonary and Critical Care Societies in 2000 found that, of the 10,244 practicing U.S. physicians that classified themselves as critical care providers, nearly half did not hold a formal critical care certification.⁵  A 2013 study by the Health Resources and Services Administration (HRSA) took duty hour variation into account, reporting only 3,570 full-time equivalent intensivist physicians and 2,880 full-time equivalent critical care nurse practitioners.⁶  The most recent published estimates are based on data from 2015, though the ongoing COVID-19 pandemic response warrants further updates.⁷  Using data from the 2020 National Plan and Provider Enumeration System (NPPES) National Provider Identifier (NPI) Registry, this Data Note quantifies the availability of providers capable of providing critical care in each state relative to state-level population.

Key Takeaways

• Approximately 16,600 intensivists and 67,900 critical care nurses, including certified registered nurse anesthetists (CRNAs), were identified in the United States. At the state level, these counts correspond to an average of 0.62 intensivists and 2.54 critical care nurses per 10,000 adults.
• There are also nearly 116,000 second-line physicians—hospitalists, pulmonologists, and anesthesiologists—who do not have formal critical care training, but who may be caring for critically ill patients. Across the states, these providers average 4.32 per 10,000 adults.
• Individual state-level provider concentrations varied widely. Several states that have recently reported a surge in cases have per-population numbers of intensivists or critical care nurses that are substantially lower than national average ratios, such as California, Arizona and Texas. Estimates per 10,000 adults are reported in Table 1.

Discussion

These estimates highlight several issues relevant to both the baseline critical care workforce in the U.S. and to the response to the coronavirus pandemic. Notably, the number of intensivist physicians is substantially smaller than that of “second-line” providers that sometimes provide critical care, such as hospitalists, pulmonologists, and anesthesiologists, lending credence to longstanding concerns that intensivists are in short supply in the U.S. at baseline. However, it is unclear how many of these second-line providers could be readily redirected into the ICU setting. Many hospitalists likely can be, since most practice in the hospital setting. However, significant numbers of anesthesiologists and pulmonologists may primarily practice in non-hospital settings such as ambulatory surgery centers and outpatient physician offices, and may have little experience providing ICU-level care. Similarly, the number of nurses specifically trained in critical care also appears relatively small compared to prior estimates, suggesting that the source data may lack comprehensive records for some categories of nurses that provide critical care.

Furthermore, recent increases in COVID-19 cases in several states may justify redirection of second-line providers into critical care roles, as well as recruitment of intensivists and critical care nurses from other regions, as the pandemic intensifies. Both approaches may be facilitated by volunteer programs and state government proposals similar to those that supported prior workforce expansions in New York.⁸ 

Finally, providers outside of the hospital setting will also play instrumental roles in the pandemic response, both by reducing strain on hospitals and by providing direct COVID-19 care. For example, long-term care and skilled nursing facilities are continuing to be disproportionately impacted, increasing their demand for additional personnel as well.⁹  Similarly, sufficient numbers of primary care physicians and other ambulatory care providers are vital, not only to help minimize avoidable hospitalizations through monitoring of their patients’ chronic conditions, but also to coordinate essential follow-up care for recovering COVID-19 patients after hospital discharge.

National and state leaders are facing challenging decisions about where to allocate limited resources, including critical care providers. Estimates of the current workforce size and distribution can help inform these decisions, though they must be interpreted in conjunction with local factors such as disease burden, health care infrastructure, workplace safety, and the availability of funding and medical resources. The interactions between these factors are complex and will require continuous re-evaluation in order to best protect both patients and health care personnel during the pandemic.

1. Emanuel, Ezekiel, et. al. 2020. “Fair Allocation of Scarce Medical Resources in the Time of COVID-19”. N Engl J Med. https://doi.org/10.1056/NEJMsb2005114 ↩︎
2. Halpern, N. A. and Tan, K. S. 2020. U.S. ICU Resource Availability for COVID-19. Mount Prospect, IL: Society of Critical Care Medicine. https://sccm.org/Blog/March-2020/United-States-Resource-Availability-for-COVID-19?_zs=OdHjd1&_zl=w9pb6   ↩︎
3. Weled, Barry, et. al. 2015. “The Importance of Process of Care and ICU Structure to Improved Outcomes: An Update from the American College of Critical Care Medicine Task Force on Models of Critical Care”. Critical Care Medicine. Jul; 43(7): 1520-1525. https://journals.lww.com/ccmjournal/Abstract/2015/07000/Critical_Care_Delivery __The_Importance_of_Process.19.aspx ↩︎
4. Pastores, Stephen, et. al. 2015. “Intensivist Workforce in the United States: The Crisis is Real, Not Imagined”. Am J Respir Crit Care Med. Mar; 191(6): 718-719. https://www.atsjournals.org/doi/full/10.1164/rccm.201501-0079LE ↩︎
5. Angus, Derek, et. al. “Current and Projected Workforce Requirements for Care of the Critically Ill and Patients with Pulmonary Disease: Can We Meet the Requirements of an Aging Population?” JAMA. Dec; 284(21): 2762-2770. https://jamanetwork.com/journals/jama/fullarticle/193318 ↩︎
6. National Center for Health Workforce Analysis. 2013. Health Workforce Projections: Critical Care Physicians and Nurse Practitioners. Rockville, MD: Health Resources and Services Administration. https://bhw.hrsa.gov/sites/default/files/bhw/health-workforce-analysis/research/projections/critical-care-fact-sheet.pdf ↩︎
7. Halpern, N. A., et. al. 2019. “Intensivists in U.S. Acute Care Hospitals”. Critical Care Medicine. Apr; 47(4): 517-525. https://www.ncbi.nlm.nih.gov/pubmed/30694817 ↩︎
8. Simmons-Duffin, Selena. March 25, 2020. “States Get Creative to Find and Deploy More Health Workers in COVID-19 Fight”. NPR. Accessed July 3, 2020. https://www.npr.org/sections/health-shots/2020/03/25/820706226/states-get-creative-to-find-and-deploy-more-health-workers-in-covid-19-fight ↩︎
9. McMichael, Temet; Currie, Dustin; et. al. 2020. “Epidemiology of COVID-19 in a Long-Term Care Facility in King County, Washington”. N Engl J Med. (epub ahead of print) https://www.ncbi.nlm.nih.gov/pubmed/32220208 ↩︎
10. Centers for Medicare and Medicaid Services. 2020. National Plan and Provider Enumeration System (NPPES) Data Dissemination Monthly National Provider Identifier (NPI) File (May 12, 2020). Baltimore, MD: Centers for Medicare and Medicaid Services. Accessed May 20, 2020. https://download.cms.gov/nppes/NPI_Files.html   ↩︎
11. United States Census Bureau. 2020. 2019 National and State Population Estimates. Suitland, MD: United States Census Bureau. Accessed July 16, 2020. https://www.census.gov/newsroom/press-kits/2019/national-state-estimates.html ↩︎

Coronavirus: Reopening, Schools, And The Government Response

Key Findings

• Amid a surging coronavirus pandemic and record numbers of new cases in many states, the latest KFF Health Tracking Poll finds most U.S. adults feel the worst effects of the pandemic are yet to come, and seven in ten (including four in ten Republicans) rate the federal government response to the pandemic as fair or poor. The survey also indicates that the pandemic is increasingly taking an emotional toll, with a majority of U.S. adults (53%) saying that worry and stress related to coronavirus has had a negative impact on their mental health, up from 39% in May.
• With Congress set to consider its next coronavirus relief package, a clear majority of the public across political party affiliation says that top priority should be given to increasing federal funding for efforts to limit the spread of the virus such as testing, contact tracing, and personal protective equipment for essential workers. Most Democrats, and about half of independents and Republicans, also say Congress should prioritize increasing federal support for state and local governments to help schools reopen safely. Large shares of the public also see various measures to bolster individuals’ financial health and increase access to health insurance amid the economic downturn as important things for Congress to tackle, though partisans divide on the priority that should be placed on these measures.
• With the new school year quickly approaching, the issue of whether and how to reopen schools looms large for both parents and policymakers. On balance, most parents with kids in school (60%) say it is better to open schools later to minimize infection risk, even if students miss out on academics and social services and some parents will not be able to work, while about half as many (34%) say it’s better to open schools sooner so parents can work and kids can get services, even if there’s some risk of infection. A majority (71%) of the public overall say that public schools in their area need more resources to reopen safely, and 66% of parents say the same about their own child’s school. Parents of color are more likely than White parents to say it is better for schools to open later to minimize infection risk, and to say that their own child’s school lacks the resources it needs to reopen safely.¹ 
• Parents – particularly parents of color and those with lower incomes – have a variety of worries related to both a school reopening scenario, and one in which schools remain closed. When it comes to reopening, majorities are worried that their child, family members, or teachers may get sick from the virus, and most also worry about schools’ and students’ ability to comply with physical distancing and other public health guidance. If schools don’t reopen, about two-thirds of parents are worried about their children falling behind socially and emotionally (67%) and academically (65%), and about half worry about losing income if they can’t go to work (51%) or not being able to pay enough attention to their kids if they’re working at home (47%). The inability to access other services schools provide is a concern for some parents: 40% worry about their child not getting needed social services if schools remain closed, 31% worry they won’t have access to technology needed for online learning, and 24% worry about their children having enough food to eat at home. Many of these worries – both about the risks of school reopening and the loss of learning and social services – are much higher among parents of color and those with lower incomes than they are among White and higher-income parents.
• The latest KFF Health Tracking Poll also finds that more than four months in, the coronavirus pandemic continues to take an economic toll on Americans. Four in ten report trouble affording basic necessities or falling behind on household or medical bills in the past 3 months, including 22% who say they experienced this directly because of coronavirus and its impact on their financial situation, and 17% who say they were experiencing these problems before coronavirus.

View On The State Of The Pandemic And Government Response

With a mounting death toll and coronavirus cases surging throughout much of the U.S., a majority of the public (60%) think that the worst is yet to come, up from 50% in May, though not as high as the 74% of adults in early April who thought things were likely to get worse. One in five adults (20%) currently think that the worst of the coronavirus outbreak is behind us. The overall numbers mask a deep partisan divide, with a slight majority of Republicans saying either “the worst is behind us” (31%) or that they don’t think the coronavirus is or will be a major problem (23%), while about eight in ten Democrats (79%) and a majority of independents (57%) say “the worst is yet to come.”

Amid what many see as a botched federal response to the virus, about half of U.S. adults (48%) rate the federal government response to the pandemic as “poor” while another 23% call it “fair.” Just 28% rate the federal response as “good” or “excellent.” Even among Republicans, who are generally supportive of President Trump and his Administration, 42% rate the federal government response to the pandemic as “fair” or “poor.” The public is more divided when it comes to assessing state and local governments, with about half of adults giving their state (46%) and local (48%) governments positive marks.

Majorities Across Parties Say Congress Should Prioritize Funding For Testing And Contact Tracing

As Congress discusses its next coronavirus relief package, there are reports that the Trump Administration is resisting allocating additional federal funds for coronavirus testing, contact tracing, and other prevention measures. This is at clear odds with the public’s priorities; when asked about a number of potential actions Congress could take, the highest-ranked priority among the public is increasing federal funding for efforts to limit the spread of coronavirus, such as testing, contact tracing, and personal protective equipment for essential workers. Seven in ten adults overall (72%) say this should be a top priority for Congress, including majorities of Democrats, independents, and Republicans. Schools are another popular priority: a majority (55%) say increasing federal funding to state and local governments to help schools reopen safely should be a top priority, including about two-thirds of Democrats (68%) and about half of independents (53%) and Republicans (48%).

Other measures to provide economic relief or extend insurance benefits are seen as important by large shares of the public overall, but have less broad appeal across partisans. For example, about half the public overall say increasing government financial assistance to help Americans who do not get health insurance from their jobs pay for coverage (52%) and providing financial assistance for people who have lost their jobs to purchase COBRA insurance through their former employers (49%) should be top priorities. However, there are large partisan gaps, with Democrats 42 percentage points more likely than Republicans to say Congress should place a top priority on increasing government financial assistance for individual health insurance, and 26 percentage points more likely to say Congress should place a top priority on providing assistance for people to purchase COBRA coverage.

About four in ten overall say other actions should be top priorities for Congress, including increasing funding to states to help pay for Medicaid (44%), sending a second round of stimulus checks to individuals (43%), guaranteeing every American a basic income until the pandemic passes (42%), creating a public option health insurance plan (41%), and extending the additional unemployment benefits set to expire at the end of July (39%). Views on each of these measures are marked by large partisan differences, with about six in ten Democrats saying each should be a top priority, compared with about a quarter of Republicans.

Views On The Pace Of Reopening, Including Schools

With coronavirus cases surging in many states that took an early approach to reopening, a plurality (45%) of adults overall say their state is moving at about the right pace in easing social distancing restrictions and opening businesses, while three in ten (31%) say their state is moving “too quickly” and about one in five (22%) say their state is opening “too slowly.” Views on reopening vary by both partisanship and location. Democrats are about three times as likely as Republicans to feel their state is moving too quickly, while Republicans are about three times as likely as Democrats to feel their state is moving too slowly. Notably, about four in ten adults (39%) in states that are current coronavirus hotspots (based on case data as of July 18) say their state is moving too quickly to reopen, compared to about one in four (24%) in non-hotspot states.² 

Public And Parents Prefer To Delay School Openings To Mitigate Risk

With the new school year quickly approaching, the issue of whether and how to reopen schools for in-person instruction has been at the forefront of discussions for both parents and policymakers. President Trump has stated that he wants schools to reopen for in-person instruction in the fall, and has even suggested that the federal government may withhold money from schools that don’t reopen. When asked to weigh the risks vs. benefits, a majority of the public (63%) thinks it is better to open schools later to ensure the risk of getting coronavirus is as low as possible, even if it means some students will fall behind academically or miss out on services and some parents will be unable to return to work. About a third (32%) think it is better to open schools sooner so that parents can work and students won’t miss out on learning and other services, even if there is some risk to teachers, students and staff. There is a large partisan gap on this issue among the public overall, with 87% of Democrats and 59% of independents preferring schools open later while six in ten Republicans (60%) prefer that schools open sooner.

Among parents with a child age 5-17 that normally attends school, six in ten (60%) think it is better to reopen schools later in order to ensure the risk of coronavirus is as low as possible, while about half as many (34%) think it is better to reopen sooner. Parents of color (76%) are even more likely to prefer a later reopening compared to their White counterparts (51%).

The public’s caution towards reopening schools may be reinforced by a sense that schools do not have the necessary resources to safely reopen in a manner that complies with public health recommendations on how to minimize the risk of spreading coronavirus. Seven in ten adults overall say that public schools in their area need more resources in order to safely reopen, while just 22% say schools have enough resources. This sentiment is echoed by parents of school-aged children when they are asked about their own child’s school. Two-thirds of parents (66%) say their child’s school needs more resources in order to safely reopen. Notably, parents of color are more likely than their White counterparts to say their child’s school lacks the resources necessary to safely reopen (82% vs. 54%).

Parents – Particularly parents of color and those with Lower Incomes – Worry about both school reopening And remaining closed

With many schools’ academic year commencing in August and early September, about half of parents with children who typically attend school (52%) said their child’s school had not yet announced whether they would be having in-person classes this fall at the time they took the survey. This month’s poll asked parents about worries related to both a school reopening scenario and one in which schools remain closed to in-person instruction. When it comes to reopening, large shares of parents with a child enrolled in school are worried about teachers and staff getting sick from coronavirus (79% very or somewhat worried) and children being unable or unwilling to comply with physical distancing practices (73% very or somewhat worried). About seven in ten are also worried about their child (70%) or themselves or a family member (69%) getting sick from coronavirus, while two-thirds (66%) worry about their child’s school being unable to comply with public health recommendations.

Reflecting the disproportionate impact of the coronavirus pandemic on those with lower incomes and on communities of color, there are some notable differences in worry levels between parents of color and White parents, and between those with lower and those with higher household incomes. Nine in ten parents of color (91%) say they are either “very worried” or “somewhat worried” about their child getting sick with coronavirus if they return to school in the fall, compared to 55% of White parents who say the same. Similarly, about nine in ten of parents of color say they are worried about teachers and other staff getting sick with coronavirus (92%), children being unable or unwilling to physically distance (91%), and that they or a family member will get sick with coronavirus (90%). Far fewer White parents say they are worried about each of these concerns.

In addition, parents who have a household income under $90,000 are more likely than their higher-income counterparts to say they are worried about children being unable or unwilling to physically distance (82% vs. 62%) or teachers and staff getting sick from the coronavirus (84% vs. 73%).

Parents also express a number of worries related to schools remaining closed for in-person instruction in the fall. If schools don’t reopen, about two-thirds of parents say they would worry about their children falling behind socially and emotionally (67%) and academically (65%), and about half say they would worry about losing income if they can’t go to work (51%) or not being able to pay enough attention to their kids if they’re working at home (47%). Other services schools provide are also a concern for some parents: 40% worry about their child not getting needed social services if schools remain closed, 31% worry they won’t have access to technology needed for online learning, and 24% worry about their children having enough food to eat at home.

Similar to the findings on parental worries about their child returning to school in-person in the fall, parents of color and those with lower household incomes are also more likely than their counterparts to say they worry about possible outcomes if their children do not return to in-person classes.

Parents of color are more likely than White parents to say they are “very worried” or “somewhat worried” about their child not getting social services they usually get at school (52% vs. 32%), are almost three times as likely to worry their child won’t have access to the technology needed for online learning (49% vs. 17%), and about five times as likely to worry their child will not have enough to eat at home (44% vs. 9%). Parents of color are also more likely than White parents to worry about losing income if they are unable to work outside the home (65% vs. 41%).

Similarly, parents with household incomes under $90,000 more likely than their higher income counterparts to be worried that their child will not have access to social services they usually get at school (47% vs. 26%), will not have enough to eat at home (34% vs. 6%), or won’t have access to the technology needed for online learning (43% vs. 10%). Moreover, lower-income parents are more likely than those with higher incomes to worry about losing income if they are unable to work outside the home (61% vs. 35%).

The Continuing Impact Of The Coronavirus Pandemic On Mental Health, Wellbeing, And Financial Health

over half report a negative impact on mental health

As life with the coronavirus pandemic wears on, Americans increasingly say it is taking a negative toll on their mental health. For the first time since KFF began tracking this question in March, a majority of adults (53%) now say that stress and worry related to the pandemic has had a negative impact on their mental health. This is up 14 percentage points since May, and up 8 percentage points since the previous high of 45% in early April. About one in four (26%) say worry and stress related to coronavirus has had a “major impact” on their mental health, while a similar share (28%) say it has had a “minor impact.”

Notably, younger adults are more likely older adults, and women are more likely than men, to say stress and worry related to coronavirus has had a negative impact on their mental health. About seven in ten Blacks adults (68%) and those who have had difficulty paying household bills in the past three months due to the financial impact of the coronavirus outbreak (71%) say that stress and worry related to the pandemic has had a negative impact on their mental health.

In addition to reporting a general negative impact on their mental health, about half (52%) of adults report that worry and stress related to the coronavirus outbreak has had adverse effects on their mental health and wellbeing in specific ways. About a third say coronavirus-related worry or stress has led to problems with their sleep (36%) or has led to a poor appetite or overeating (32%). About one in five say worry or stress related to the pandemic has caused them to experience frequent headaches or stomachaches (18%) or difficulty controlling their temper (18%), while 12% each say it has led to increased alcohol or drug use or worsening chronic health conditions.

Mirroring the findings on overall negative impact on mental health, younger adults and women are more likely than their counterparts to say coronavirus-related stress has caused adverse effects on their mental health or wellbeing. Notably, three in four adults who have had difficulty paying household bills in the past three months due to the financial impact of coronavirus say they have also experienced adverse effects their mental health and wellbeing, as do about six in ten Hispanic adults and Black adults.

four in ten have problems affording household expenses or health care

With the country facing a double-digit unemployment rate, four in ten adults say they or an adult in their household has had problems paying bills or difficulty affording medical care or basic expenses in the past three months. This includes about one in five who say they have fallen behind on their credit card bills (22%), 18% who have had trouble affording health insurance, and similar shares who say they have had trouble paying medical bills (17%), paying for food (17%), paying utility bills (17%) or have fallen behind on their rent or mortgage (17%). Additionally, 12% say they have had problems affording their prescription medications. Notably, among the 40% of adults who have experienced difficulty paying household or medical bills in the last three months, most (54%, or 22% of all adults) say it was due to the coronavirus outbreak and its impact on their financial situation, while 42% (17% of all adults) say this something they were already experiencing before the pandemic.

Coronavirus and the 2020 Election, ACA

Key Findings

• Less than four months before the 2020 presidential election, the latest KFF Health Tracking Poll finds President Trump receiving his lowest ratings ever from voters on his handling of the coronavirus outbreak. President Trump still garners majority support from Republican voters on all key issues.
• With the number of coronavirus cases in the U.S. now exceeding 4 million people, nearly twice as many voters give President Trump negative marks on his handling of this issue as give him positive marks (61% v. 35%).
• The July poll also explores how two key groups of voters for the 2020 election (swing voters and Electoral College battleground voters) view the job President Trump is doing. About half of these voters approve of President Trump’s handling of the U.S. economy, but similar to overall voters, they disapprove of his handling of other issues.
• President Trump also receives low marks on his handling of health care and the Affordable Care Act, the 2010 health care law which the Trump administration is currently challenging in court. About one-third of voters say they approve of the president’s handling of health care generally (35%) and the Affordable Care Act specifically (33%). Partisans have very different views on President Trump’s handling on both of these issues with most Democrats disapproving while majorities of Republicans approving.
• The public’s views of the Affordable Care Act have largely remained unchanged over the course of the coronavirus pandemic, with half of the public continuing to view the law favorably. There are strong partisan differences in how the public views both the ACA and the pending Supreme Court case challenging the legality of the 2010 law, with Republicans overwhelmingly wanting to see the law overturned while most Democrats want to see the ACA remain in place and largely disapprove of recent Trump administration actions challenging the law.

The 2020 Election

Four months out from 2020 election, voters give President Trump negative ratings on his overall job approval as well as his handling of key issues that will likely decide the election President Trump also now garners his lowest net approval on the handling of the coronavirus outbreak in the U.S. since KFF began polling on the topic. One-third (35%) of voters approve of his handling of the coronavirus outbreak in the U.S. while six in ten (61%) voters disapprove (net approval of -26 percentage points). President Trump also receives negative ratings on his handling of health care more broadly (net approval of -21 percentage points) as well as his handling of the Affordable Care Act (net approval of -21 percentage points). While President Trump had previously received positive marks on his handling of the economy, voters are now split with 47% approving of his handling of the nation’s economy, and 50% disapproving (resulting in a negative net approval—approval minus disapproval—of -3 percentage points). Overall, four in ten voters (41%) approve of how President Trump is handling his job as president while a majority disapprove (56%).

Voters’ attitudes on President Trump’s handling of both the economy and the coronavirus outbreak have dropped sharply since May 2020. The latest KFF Health Tracking Poll finds President Trump’s overall net approval on these two key issues has dropped nearly 20 percentage points over the course of the summer (economy: 19 percentage point drop in net approval; coronavirus: 18 percentage point drop in net approval).

Voters’ opinions of President Trump’s handling of the issues probed in the poll are largely partisan, with Republicans giving him much higher marks across all of the issues asked about. Majorities of Republican voters approve of President Trump’s handling of his job as president (84%), the economy (87%), health care (78%) and the coronavirus outbreak in the U.S. (74%), yet his net approval on each of these issues is down by double digits among Republicans since May.

2020 Voters to Watch: Swing Voters

Swing voters, a crucial group of voters who have not yet decided which candidate they will vote for in November, are also negative in their assessments of President Trump’s presidency and his handling of most national issues – but remain positive in their assessment of his handling of the economy. Swing voters (who comprise 29% of all voters) largely disapprove (57%) of the way President Trump is handling his job overall and are also negative in Trump’s handling of both the coronavirus outbreak (66% disapprove) and health care (58% disapprove).

Swing voters are more positive in views of how President Trump is handling the economy, but at a smaller margin than their assessments in May, with a net approval of +5 percentage points compared to +19 percentage point net approval in May. Swing voters’ assessments of Trump’s handling of health care and the coronavirus outbreak have also become more negative, with the assessments of the president’s handling of health care down 8 net percentage points, and the current coronavirus outbreak down 14 net percentage points.

2020 Voters to Watch: Electoral College Battleground Voters

Another important group of voters to watch in 2020 are voters living in states where the election outcome is less predictable. The attitudes of these Electoral College battleground voters will be important in the upcoming election, as their states and districts are likely to swing the Electoral College towards President Trump or Joe Biden.³  This group of voters, representing 38% of all voters, are evenly split in their party preferences, with three in ten saying they are Democrats, Republicans and Independents (31%, 30% and 31% respectively).

President Trump fares slightly better with these battleground voters on all key issues. Half of these voters approve of President Trump’s handling of the economy and 45% say they approve of his handling of his job as president. But similar to the views of all voters and swing voters, President Trump fares slightly worse on his handling of health care and the coronavirus outbreak in the U.S.. Partisan voters in these battleground states and districts fall largely along the same party lines in their evaluations of President Trump, as partisan voters overall.

The Affordable Care Act

The public’s attitudes towards the 2010 Affordable Care Act (ACA) have remained relatively unchanged over the past 5 months, with half (51%) now saying they hold a favorable opinion of the law, while 36% hold an unfavorable view.

Partisans continue to hold different views of the ACA, with about eight in ten Democrats (79%) holding favorable views while seven in ten Republicans (72%) view the law unfavorably. Half of independents hold favorable views (51%) while a smaller share (35%) say they view the law unfavorably.

On June 25^th, 2020, the Trump administration issued a brief asking the U.S. Supreme Court to overturn the entire Affordable Care Act. The brief was filed in support of an ongoing challenge to the ACA by a group of Republican attorneys general in California v. Texas, a case that challenges the legality of the ACA in light of the zeroing out of the individual mandate penalty in the 2017 Tax Cuts and Job Acts. While there is a possibility that the case may be heard in the days leading up to the 2020 election, no opinion is expected to be issued until 2021.

Republicans largely approve (77%) of the Trump administration’s actions, while the vast majority of Democrats (91%) as well as more than half of independents (55%) disapprove of the Trump administration asking the Supreme Court to overturn the ACA.

If the Supreme Court sides with the Trump administration and the coalition of Republican attorneys general, all or parts of the 2010 Affordable Care Act would no longer be the law of the land. About half (53%) of the public do not want to see the ACA overturned by the Supreme Court while four in ten (38%) say they want to see the law overturned. Once again, attitudes are largely partisan with eight in ten Democrats (82%) and half of independents (51%) not wanting the law overturned, while seven in ten Republicans say the Supreme Court should overturn the 2010 health care law. Previous KFF polling has found that majorities across partisans want many of the ACA’s protections to remain in place.

This KFF Health Tracking Poll was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF). The survey was conducted July 14-19, 2020, among a nationally representative random digit dial telephone sample of 1,313 adults ages 18 and older, living in the United States, including Alaska and Hawaii (note: persons without a telephone could not be included in the random selection process). The sample included 292 respondents reached by calling back respondents that had previously completed an interview on the KFF Tracking poll at least nine months ago. Computer-assisted telephone interviews conducted by landline (323) and cell phone (990, including 714 who had no landline telephone) were carried out in English and Spanish by SSRS of Glen Mills, PA. To efficiently obtain a sample of lower-income and non-White respondents, the sample also included an oversample of prepaid (pay-as-you-go) telephone numbers (25% of the cell phone sample consisted of prepaid numbers) as well as a subsample of respondents who are parents of children ages 5 to 17 who had previously completed interviews on the SSRS Omnibus and Sports polls (n=101). Both the random digit dial landline and cell phone samples were provided by Marketing Systems Group (MSG). For the landline sample, respondents were selected by asking for the youngest adult male or female currently at home based on a random rotation. If no one of that gender was available, interviewers asked to speak with the youngest adult of the opposite gender. For the cell phone sample, interviews were conducted with the adult who answered the phone. KFF paid for all costs associated with the survey.

The combined landline and cell phone sample was weighted to balance the sample demographics to match estimates for the national population using data from the Census Bureau’s 2018 American Community Survey (ACS) on sex, age, education, race, Hispanic origin, and region along with data from the 2010 Census on population density. The sample was also weighted to match current patterns of telephone use using data from the January-June 2019 National Health Interview Survey. The weight takes into account the fact that respondents with both a landline and cell phone have a higher probability of selection in the combined sample and also adjusts for the household size for the landline sample, and design modifications, namely, the oversampling of prepaid cell phones and likelihood of non-response for the re-contacted sample. All statistical tests of significance account for the effect of weighting. The sample of parents with school-age children was weighted by: gender, age, educational attainment, race/ethnicity, and Census region.

The margin of sampling error including the design effect for the full sample is plus or minus 3 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available by request. Note that sampling error is only one of many potential sources of error in this or any other public opinion poll. Kaiser Family Foundation public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

1. Due to sample size limitations, we analyzed parents who are Black, Hispanic, Asian, other races, or mixed race as a group (referred to as “parents of color”) compared to their White counterparts. We recognize these groups all have unique experiences; however, the sample size of the poll does not provide sufficient numbers of parents in each of these individual racial/ethnic groups to break out separately. ↩︎
2. States were categorized as coronavirus hotspots based on data available from KFF’s COVID-19 Metrics By States on July 20th, 2020 and qualified as a hotspot if cases had increased by 5% of more in the past 14 days and the positivity rate (14-day rolling average) was 10% or greater or if the positivity rate had increased by more than 1 percentage point in the past 14 days. ↩︎
3. Using the Cook Political Report’s 2020 Electoral College Ratings, the category of voters living in states and districts classified as “Toss-up”, “Lean Democrat”, and “Lean Republican” are analyzed as Electoral College voters. Voters in this category live in Michigan, Minnesota, Nebraska 2nd CD, New Hampshire, Pennsylvania, Wisconsin, Arizona, Florida, Georgia, Maine 2nd CD, North Carolina, Iowa, Ohio and Texas, constituting 195 volatile electoral votes.   ↩︎