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Transcript
SPEAKER_2
[00:00:17] Welcome to everyone who has joined. We’ll begin shortly—just letting everyone file in. Thank you for joining us today for Aging Services and Long-Term Care in Transition: Preparing for the Road Ahead with our guests Brendan Williams and Irving Stackpole. Irving, would you like to say something?
SPEAKER_1
[00:02:04] Welcome, everyone. Thanks for joining us. I hope this will be a vigorous conversation. I’m delighted that Brendan is with us. He’s an insightful thinker who has established himself as a true authority in long-term care and skilled nursing. Without further ado, Brendan.
SPEAKER_0
[00:02:29] Thank you for that generous introduction, Irving. Remind me to give you the money I promised for that! But seriously, it’s great to have this opportunity to discuss long-term care—obviously a subject of great interest for us and of academic interest to me as well.
Next slide, Emily. One of the key challenges we face, which Irving will also address, is the workforce. In New Hampshire, we typically have one of the lowest unemployment rates in the United States. While this might give you insight into a state-specific issue, it’s a challenge nationwide.
The good news is that the workforce shortage has steadily diminished since the pandemic began. The bad news is that, under normal circumstances, you would expect to have more staff now than at the start of the pandemic in February 2020. Instead, many facilities are struggling to recruit workers.
For example, in New Hampshire, county-run facilities—remnants of the county poor farm system—offer union wages and benefits. Despite this, some facilities have had to take 50 beds offline and maintain waitlists of up to 100 prospective residents, all due to staffing shortages. Facilities simply cannot take in residents they cannot serve, which jams up hospitals.
We are in ongoing discussions with our hospital partners about solutions. If hospitals cannot discharge patients ready for nursing home care, they lose revenue, leading to issues like emergency department boarding. This is not just a New Hampshire problem—it’s nationwide.
Facilities closing only make this worse, particularly in rural areas where a closure can severely impact hospital discharge capacity. And frankly, no one wants to be in a hospital unnecessarily when nursing homes or home and community-based settings are more appropriate.
Next slide, Emily. In New Hampshire, we face a specific problem: an exodus of licensed workers to Massachusetts. Despite New Hampshire’s reputation as a prosperous state, Massachusetts simply pays more for direct care workers. This disparity makes it hard to retain nursing graduates or workers.
We passed legislation last year to address this, but in classic New Hampshire fashion, it wasn’t funded. I speak to nursing students often, and when I ask if they’ll stay in New Hampshire, the answer is often no. This highlights a larger issue: healthcare is stuck in a “Hunger Games” model of workforce scarcity, exacerbated by pre-pandemic shortages.
We have a 12% RN vacancy rate and a 22% vacancy rate for LNAs (licensed nursing assistants)—positions that are critical to care. Nursing homes cannot compete with hospitals for wages because they lack the revenue streams hospitals have.
Next slide, Emily. This issue underscores why the CMS staffing mandate proposed under the Biden administration would have been impossible to meet. It’s not about opposition to quality care—it’s about feasibility. New Hampshire’s two Democratic senators and one House member opposed the mandate, recognizing this reality.
The mandate would have required nursing homes to have RNs on duty 24/7, a significant jump from the current statutory requirement of eight hours a day. For small facilities—like our 22- and 24-bed homes serving nuns—it’s simply unworkable. Adding staff under these conditions isn’t feasible, particularly when the workforce doesn’t exist.
Next slide, Emily. Nursing homes operate under extensive regulations—more than many sectors, including nuclear power. Yet, Xavier Becerra, the outgoing HHS Secretary, called nursing homes the “Wild West,” a statement I found absurd.
These challenges have been worsened by inflation and the increasing dominance of Medicare Advantage. Medicare Advantage plans have reduced payments to nursing homes and denied care through algorithms, creating additional financial pressure. As Medicare Advantage enrollment grows, it threatens the traditional Medicare revenue that nursing homes rely upon to offset Medicaid underfunding.
Next slide, Emily. Since the pandemic began, over one-third of New Hampshire’s nursing homes have been sold. Some assume this indicates profitability, but the reality is that only those with deep pockets can afford to play the long game. Nursing homes are a precarious investment, and we desperately need solutions to address long-term care funding at both state and federal levels.
With that, I’ll turn things over to Irving.
SPEAKER_1
[00:21:19] Thank you, Brendan. Excellent points, as usual. I’ll attempt to address some of these challenges, particularly the growing gap between supply and demand. This issue isn’t just about economics—it’s driven by demographics and compounded by workforce shortages, regulatory burdens, and systemic inefficiencies.
SPEAKER_1
[00:21:19] Demographics are destiny. The demand for long-term care will skyrocket as the 85-plus population grows. Consumption of services increases exponentially at this age, and the data shows we’re not prepared.
We’re emerging from a dip in live births, but by 2030, the demographic curve will steeply climb. This translates to an oncoming wave of older adults needing care—one we’re structurally unprepared to meet.
The challenge is compounded by limited ability to pay. A growing cohort of older individuals falls into the ALICE category—Asset Limited, Income Constrained Consumers. These individuals can’t afford private care, and Medicaid remains the safety net. Unfortunately, Medicaid reimbursement often falls short of covering actual care costs.
We’re also seeing a growing number of older adults who are aging at home alone. Harvard’s Joint Center for Housing Studies has published staggering projections of individuals aged 80+ living alone in single-family homes. Loneliness, limited access to services, and the challenge of liquidating home equity to pay for care create a perfect storm.
Let’s talk about supply. Nursing homes, assisted living, and independent living are part of the broader long-term care continuum. However, while independent and assisted living remain somewhat elastic in supply, skilled nursing is contracting rapidly. From 2015 to 2035, CMS data shows a steady decline in available SNF beds, while the number of individuals requiring skilled nursing care—those with neurodegenerative and musculoskeletal conditions—continues to grow.
The result? A gap between demand and supply. This gap doesn’t just mean constipated ERs or delayed discharges; it means vulnerable individuals left without care—sometimes dying alone at home.
As Brendan highlighted, facilities lack resources to renovate, replace, or expand. Most facilities are old, crowded, and inadequate to meet modern needs. This was a known issue long before COVID-19. Yet Medicaid reimbursement simply doesn’t support infrastructure investment or workforce growth.
SPEAKER_2
[00:40:22] Thank you, Irving. We have a question from the audience: Will the new administration continue to push minimum staffing regulations, and what other changes might Trump 2.0 bring?
SPEAKER_0
[00:41:00] The staffing mandate will likely be abandoned, whether administratively or through Congress. However, there are concerns with any push to cut federal spending. Medicaid, in particular, remains vulnerable to reductions, such as the elimination of provider taxes or matching funds for Medicaid expansion.
Another critical concern is immigration. If we fail to achieve immigration reform, we won’t have the workforce to care for aging Americans. There simply aren’t enough American-born workers to meet demand.
SPEAKER_1
[00:43:08] I agree with Brendan. My greatest concern is the power of the insurance industry under a Trump 2.0 administration. The healthcare lobby—led by insurers—is the second-largest in Congress. Medicare Advantage, for instance, is siphoning public funds into private enterprises.
If I may editorialize for a moment, what we need is a federal long-term care insurance system. Japan faced far worse aging demographics but successfully implemented a national LTC program over a decade ago. Such a system could alleviate pressure on Medicaid, which currently crushes state budgets.
SPEAKER_2
[00:46:25] Thank you both. Another audience question: How can we train immigrants to provide care in long-term care settings?
SPEAKER_1
[00:46:38] Great question. Step one is reinstating visa categories specifically for healthcare workers—particularly nurses, CNAs, and med techs. These categories existed before and brought tens of thousands of skilled workers, many from the Philippines, who were a tremendous asset to the U.S. healthcare system.
We should also expand these visas to include credentialed healthcare workers from other countries with robust training systems. Policies must support integrating these workers into the system quickly and safely.
SPEAKER_0
[00:48:58] I’ll add that the bigger challenge is even having immigrants to train. Immigration reform has been stalled for decades, and many qualified workers are either deported or afraid to come forward. Without reform, we’re fighting a losing battle.
SPEAKER_2
[00:50:16] Another question: How can we address entrenched ageism and find a political champion for meaningful change?
SPEAKER_0
[00:50:58] It’s a real challenge. Policymakers rarely look beyond their next election, which makes long-term solutions for long-term issues difficult to achieve. Ageism reinforces a societal attitude where aging individuals are dismissed as burdens rather than valued members of the community.
Our largest nonprofit member, Catholic Charities of New Hampshire, often highlights the moral dimensions of care. But as a society, we’ve failed to take the long view.
SPEAKER_1
[00:52:33] I respect those concerns, but I remain more optimistic. Underneath societal fatigue lies a deep-seated care for neighbors. These issues are local and personal.
However, ageism persists because of the metaphor surrounding long-term care—“nursing homes” remain associated with vulnerability, debility, and death. We’ve failed to change that narrative. We need to reframe the conversation. Think of Golden Girls—a positive depiction of congregate living. The infrastructure can improve, but cultural perceptions must change as well.
SPEAKER_0
[00:53:57] Well said, Irving. Without investments akin to the Hill-Burton Act, which revitalized hospitals in the mid-20th century, nursing homes remain outdated and overcrowded.
SPEAKER_2
[00:59:32] Thank you, everyone, for this vigorous discussion. If we didn’t get to your question today, we’ll follow up with responses via email along with the webinar recording and presentation references. If there’s anything else we can do to support you, please don’t hesitate to reach out.
Thank you again, Brendan and Irving. And happy birthday, Emily!
SPEAKER_0
[00:59:52] Thank you, Emily.
SPEAKER_1
[00:59:53] Thank you, Brendan, and thanks to everyone for joining us.
SPEAKER_0
[00:59:54] Take care, everyone.
