By Savanna Strott for Eye on Ohio, The Ohio Center for Journalism
Broadcast version by Emily Scott for Ohio News Connection.

COLUMBUS, Ohio - Ohio nursing homes reported more shortages of nursing assistants than any other state during the pandemic, highlighting a problem that has been festering for decades.

An Eye on Ohio and Investigative Reporting Workshop analysis of weekly reported data from the Centers for Medicare and Medicaid Services found that Ohio reported the highest number of shortages in the country for State Tested Nursing Assistants (STNA) in 2020 and through the first half of 2021, leaving critical care positions open and shifting work to other positions suffering shortages of their own.

Ohio has the third-highest number of nursing homes behind Texas and California, and tallied STNA shortages in 26% of reports to the Centers for Medicare and Medicaid Services (CMS). That makes Ohio the 14th worst nationwide for the percentage of nursing homes reporting too few STNAs that same year.

"We just have probably the worst shortage that we've had at least in my 35 years of doing this," said Robert Applebaum, director of the Ohio Long-Term Care Research Project at Miami University's Scripps Gerontology Center. "The industry was in trouble before COVID, and COVID has pretty much put those problems on steroids at this point."

The continuing shortage of nursing assistants, registered nurses and other staff in nursing homes has become a national issue. A June survey from the American Health Care Association and National Center for Assisted Living, which represents more than 14,000 U.S. nursing homes and long term care facilities, found that 94% of nursing homes reported a shortage of staff in the last month. Almost three-quarters of nursing homes said their workforce situation had worsened since 2020.

Quantifying shortages can be difficult because there's no minimum staffing ratios for STNAs on the federal or Ohio state level. But staffing challenges in Ohio's 950 nursing homes were a troublesome issue before nursing homes and other long-term care facilities accounted for almost 40% of Ohio's 20,500 COVID-19 deaths, according to interviews with experts, advocates and nursing home administrators.

With Ohio having the 17th oldest population in the country, the need for elder care - and the workers who provide it - will only grow in the coming years.

"By not raising the wages, by not having better staffing ratios in place, you didn't create an optimal work environment," said Monica Moran, a former organizer and lobbyist for nursing home workers with Service Employees International Union. "And so without creating that best work environment, you have less people interested in working there. And if less people are interested in working there, you have a perfect storm for the pandemic to do even more damage."

Some studies during the pandemic found that nursing homes with higher staffing levels were associated with fewer COVID-19 cases and deaths.

But nursing home administrators who spoke with Eye on Ohio and IRW said their residents wouldn't have fared any better even if there had been no staff shortages during the pandemic.

"What I think it was was a new virus that no one knew anything about," said Mary Jane Klarich, administrator of the Normandy Care Center in the Cleveland suburb of Rocky River. "The shortage didn't affect care, the number of cases or deaths. Everyone was learning and trying to get directions from the CDC."

Now nursing homes face the threat of the delta variant, which is causing a surge in cases and hospitalizations, mostly among the unvaccinated. This, coupled with only 53% of staff being vaccinated, has created concerns about vulnerable elderly residents. However, a Canton assisted living facility recently showed that a delta variant outbreak can be manageable and mild with vaccinated residents and staff.

Still, an incoming federal mandate requiring all staff in nursing homes to be vaccinated is causing concerns that it might worsen the already staggering staffing shortages in Ohio.

"The same challenges that created pain points during the height of the pandemic are the same areas that we will need continued improvement," said Latoya Peterson, the associate state director for Ohio's AARP. "That means meaningful reform around both infection control and staffing in nursing homes, and that includes common-sense legislation."

The shortage

Since Melissa Wilfong started working 18 years ago as a nursing assistant, she said she's seen a "general decline" in the number of STNAs and applications for the position. Wilfong, who has been the administrator at the Ohio Veterans Home in Sandusky since October 2020, said she's seen a decrease even in the number of people pursuing STNA certification.

That decline came to a head during the pandemic as Ohio's reported shortages remained above the nation.

In the inaugural year of COVID-19, Ohio's nursing homes reported STNA shortages in 26% of reports to CMS, compared with the national median of 21%. While about a quarter of reports in the state claim an STNA shortage, the national median fell to 18% in 2021, widening the gap between the Buckeye state and the rest of the country.

"The workforce challenges predated the pandemic," Peterson said. "But they became untenable during the pandemic."

Defining a shortage for STNAs and the effects of a reported shortage can be difficult without mandatory staffing requirements. Federal legislation through the Nursing Home Reform Act of 1987 gave standards for LPNs and RNs, but only required that nursing homes have "sufficient staffing" - no specific ratios - for nursing assistants.

Because of this, reports from nursing homes of staffing shortages during the pandemic are estimates. Instead of providing numbers of filled positions or openings, nursing homes answer yes-or-no questions if they have a shortage for different positions.

Nursing homes usually under report on such forms, Miami University's Applebaum said.

"So the fact that they're reporting these numbers as that, as high as they are, to me it's kind of scary," Applebaum said.

Shortages don't look the same from nursing home to nursing home, Wilfong said, noting that her Sandusky veterans home reported having an STNA shortage every week since data collection began in May 2020. Wilfong said she reported STNA shortages because there were open positions, but the facilities never reached a critical level.

At her previous job at a private nursing home, Wilfong said staffing levels did become untenable.

'A really hard job'

Though STNAs provide vital, direct care and companionship to residents, Wilfong said, the position doesn't receive the respect it deserves.

"They are the ones that are holding their hands when they're sick, when they're scared." Wilfong said. "They've been their families this whole pandemic because their families couldn't come in, so the aides are a vital role in any facility because they are the bedside person."

Activists, experts and nursing home administrators who talked with Eye on Ohio and IRW said that wages and workloads for STNAs were a factor in Ohio's shortage.

"With the low wages that are paid to STNAs in nursing homes, you have people who could go to McDonald's or Taco Bell and get a job that paid about the same,"said Moran, the former labor organizer. "So you're talking bottom dollar for some of these nursing facilities and a really hard job with a high level of commitment for a low wage. And that drives people out of the industry."

Data from the Paraprofessional Healthcare Institute shows that Ohio nursing assistants across health care industries, including nursing homes, hospitals and assisted living facilities, made a median hourly wage of $13.61 in 2019, about $1 less than the national median of $14.83 for all nursing assistants nationwide.

At The Normandy Care Center in suburban Cleveland, the starting hourly wage for STNAs is $14 or more based on experience, which Klarich said is a comparable wage based on a recent market survey. She added that STNA wages have to be proportional to other positions, such as licensed practical nurses and registered nurses, that require more education, licenses and skills.

At Sandusky Veterans Home, a union facility, the starting wage is $17.32 and has risen between 30 and 50 cents a year since 2016, according to internal data provided to Eye on Ohio and IRW.

But nursing home administrators were quick to point out that Ohio's critical shortage of STNAs comes at a labor shortage in the state and in the country.

"Now you're competing with pretty much the entire county because everybody is competing for that same pool," Wilfong said.

Both Wilfong and Klarich listed other businesses that offer similar or higher pay to STNAs that are also struggling to fill positions.

Klarich said increased pay alone can't help fill STNA holes: Applicants have to want to work with the elderly.

"They have to be a compassionate person that wants to help another person," Klarich said. "You have to derive some type of job satisfaction from helping and working with the elderly."

Part of this is because of the hard work STNAs have to do, Klarich said, work that became harder in the pandemic.

"It wasn't necessarily, in some cases, only staffing shortages that existed before," said Michelle Shirer, Ohio AARP's director of communications. "It was staffing shortages that existed before, plus a demand and an increase of staffing needs and what people could do."

Shirer said STNAs and other nursing home workers had the added workload of adjusting to changes from the pandemic, including sometimes becoming caregivers outside of work for family members who became sick. Inside nursing homes, STNAs workload grew as family members who often provided care for residents, such as helping them with feeding or bathing, were unable to visit.

Anthony Caldwell, vice president of public affairs for SEIU, the union that represents some nursing assistants, said he had heard stories of nursing home workers who were unable to take time off, had insufficient personal protective equipment and had to work more than their scheduled hours.

While health care workers across the country were celebrated as heroes for battling on the frontlines of the pandemic, Caldwell said the hero label was a "slap in the face" for STNAs who walked into low-wage jobs with poor benefits.

"And I just can't understand enough how much it infuriated people, especially the workers that I talked to, to see these big 'health care heroes' signs on the front of the nursing home more as a marketing gimmick than anything," Caldwell said. "But then once they got inside the facility, they didn't feel that they were treated as heroes."

This collaboration with Eye on Ohio is produced in association with Media in the Public Interest and funded in part by the George Gund Foundation.

Groups advocating for better access to health care have introduced what they call "Care4All California," a package of 13 bills designed to shore up the health system as the state braces for the possibility of huge cuts in federal funding for Medi-Cal.

The bills aim to get more people insured, connect them to care and make health care more affordable.

Chris Noble, organizing director for the nonprofit Health Access California, explained the group's priorities.

"It's crucial that our State Legislature shows their commitment to advancing a universal, affordable and equitable health care system," Noble emphasized. "This year's package of legislative and budget priorities requires no interventions by the federal government and should be adopted to safeguard our health care system in case there are federal attacks."

One bill would make sure people with Medicare supplemental insurance cannot be penalized for having preexisting conditions. Another would require hospitals to prescreen all patients to see if they are eligible for discounted or charity care programs. A third bill would allow undocumented people access to health plans on the CoveredCA exchange. Opponents cited cost concerns.

Noble emphasized the bills build on the progress California has made to lower its uninsured rate.

"These priorities will continue to cover gaps within our health care system, ensure that when people are denied or delayed care, there's certain accountability, or ensure that folks are getting access to accurate and up-to-date provider directories," Noble outlined.

Advocates have also made a number of budget requests, including one to give kids who qualify for Medi-Cal continuous coverage from birth to age 5, rather than making their parents reapply every year.

As Republican lawmakers in Washington, D.C., consider cuts to Medicaid, a new report has found thousands of veterans in Virginia could be affected.

Virginia passed Medicaid expansion in 2018, which broadened who qualified for the program, including people under 65 and without children who make 138% or less of the federal poverty level. The report by The Commonwealth Institute showed more than 47,000 Virginia veterans receive health coverage through Medicaid.

Freddy Mejia, policy director at the institute, said work requirements or cuts to the Medicaid expansion would increase barriers to Virginians' access to health care.

"We just kind of want to raise the profile of how federal cuts to Medicaid could impact not only hundreds of thousands of Virginians, nearly 629,000 Virginians that have health coverage through Medicaid expansion, but also to veterans in particular here in Virginia," Mejia outlined.

Rep. Mike Johnson, R-La., the Speaker of the House, has said the Medicaid expansion under the Affordable Care Act allowed people who did not truly need the benefit to enroll. Republicans have called for major cuts in spending across the federal government but are split on which entitlement programs should be trimmed, and by how much.

Virginia is one of eight states with what is known as an automatic trigger law in place, where states would immediately end their expansion if the federal government lowers its funding of the Medicaid expansion below 90%.

Mejia argued veterans in the Commonwealth would get caught up in the cuts.

"If the federal government decides to reduce funding for Medicaid expansion by even 1%, our state law means that it would automatically end Medicaid expansion," Mejia pointed out. "That would immediately throw potentially thousands of veterans off of coverage."

More than 20% of Virginians access health care through Medicaid.


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By Brett Kelman for KFF Health News.
Broadcast version by Freda Ross for Arkansas News Service reporting for the KFF Health News-Public News Service Collaboration

In the wooded highlands of northern Arkansas, where small towns have few dentists, water officials who serve more than 20,000 people have for more than a decade openly defied state law by refusing to add fluoride to the drinking water.

For its refusal, the Ozark Mountain Regional Public Water Authority has received hundreds of state fines amounting to about $130,000, which are stuffed in a cardboard box and left unpaid, said Andy Anderson, who is opposed to fluoridation and has led the water system for nearly two decades.

This Ozark region is among hundreds of rural American communities that face a one-two punch to oral health: a dire shortage of dentists and a lack of fluoridated drinking water, which is widely viewed among dentists as one of the most effective tools to prevent tooth decay. But as the anti-fluoride movement builds unprecedented momentum, it may turn out that the Ozarks were not behind the times after all.

"We will eventually win," Anderson said. "We will be vindicated."

Fluoride, a naturally occurring mineral, keeps teeth strong when added to drinking water, according to the Centers for Disease Control and Prevention and the American Dental Association. But the anti-fluoride movement has been energized since a government report last summer found a possible link between lower IQ in children and consuming amounts of fluoride that are higher than what is recommended in American drinking water. Dozens of communities have decided to stop fluoridating in recent months, and state officials in Florida and Texas have urged their water systems to do the same. Utah is poised to become the first state to ban it in tap water.

Health and Human Services Secretary Robert F. Kennedy Jr., who has long espoused fringe health theories, has called fluoride an "industrial waste" and "dangerous neurotoxin" and said the Trump administration will recommend it be removed from all public drinking water.

Separately, Republican efforts to extend tax cuts and shrink federal spending may squeeze Medicaid, which could deepen existing shortages of dentists in rural areas where many residents depend on the federal insurance program for whatever dental care they can find.

Dental experts warn that the simultaneous erosion of Medicaid and fluoridation could exacerbate a crisis of rural oral health and reverse decades of progress against tooth decay, particularly for children and those who rarely see a dentist.

"If you have folks with little access to professional care and no access to water fluoridation," said Steven Levy, a dentist and leading fluoride researcher at the University of Iowa, "then they are missing two of the big pillars of how to keep healthy for a lifetime."

Many already are.

Overlapping 'Dental Deserts' and Fluoride-Free Zones

Nearly 25 million Americans live in areas without enough dentists - more than twice as many as prior estimates by the federal government - according to a recent study from Harvard University that measured U.S. "dental deserts" with more depth and precision than before.

Hawazin Elani, a Harvard dentist and epidemiologist who co-authored the study, found that many shortage areas are rural and poor, and depend heavily on Medicaid. But many dentists do not accept Medicaid because payments can be low, Elani said.

The ADA has estimated that only a third of dentists treat patients on Medicaid.

"I suspect this situation is much worse for Medicaid beneficiaries," Elani said. "If you have Medicaid and your nearest dentists do not accept it, then you will likely have to go to the third, or fourth, or the fifth."

The Harvard study identified over 780 counties where more than half of the residents live in a shortage area. Of those counties, at least 230 also have mostly or completely unfluoridated public drinking water, according to a KFF analysis of fluoride data published by the CDC. That means people in these areas who can't find a dentist also do not get protection for their teeth from their tap water.

The KFF Health News analysis does not cover the entire nation because it does not include private wells and 13 states do not submit fluoride data to the CDC. But among those that do, most counties with a shortage of dentists and unfluoridated water are in the south-central U.S., in a cluster that stretches from Texas to the Florida Panhandle and up into Kansas, Missouri, and Oklahoma.

In the center of that cluster is the Ozark Mountain Regional Public Water Authority, which serves the Arkansas counties of Boone, Marion, Newton, and Searcy. It has refused to add fluoride ever since Arkansas enacted a statewide mandate in 2011. After weekly fines began in 2016, the water system unsuccessfully challenged the fluoride mandate in state court, then lost again on appeal.

Anderson, who has chaired the water system's board since 2007, said he would like to challenge the fluoride mandate in court again and would argue the case himself if necessary. In a phone interview, Anderson said he believes that fluoride can hamper the brain and body to the point of making people "get fat and lazy."

"So if you go out in the streets these days, walk down the streets, you'll see lots of fat people wearing their pajamas out in public," he said.

Nearby in the tiny, no-stoplight community of Leslie, Arkansas, which gets water from the Ozark system, the only dentist in town operates out of a one-man clinic tucked in the back of an antique store. Hand-painted lettering on the store window advertises a "pretty good dentist."

James Flanagin, a third-generation dentist who opened this clinic three years ago, said he was drawn to Leslie by the quaint charms and friendly smiles of small-town life. But those same smiles also reveal the unmistakable consequences of refusing to fluoridate, he said.

"There is no doubt that there is more dental decay here than there would otherwise be," he said. "You are going to have more decay if your water is not fluoridated. That's just a fact."

Fluoride Seen as a Great Public Health Achievement

Fluoride was first added to public water in an American city in 1945 and spread to half of the U.S. population by 1980, according to the CDC. Because of "the dramatic decline" in cavities that followed, in 1999 the CDC dubbed fluoridation as one of 10 great public health achievements of the 20th century.

Currently more than 70% of the U.S. population on public water systems get fluoridated water, with a recommended concentration of 0.7 milligrams per liter, or about three drops in a 55-gallon barrel, according to the CDC.

Fluoride is also present in modern toothpaste, mouthwash, dental varnish, and some food and drinks - like raisins, potatoes, oatmeal, coffee, and black tea. But several dental experts said these products do not reliably reach as many low-income families as drinking water, which has an additional benefit over toothpaste of strengthening children's teeth from within as they grow.

Two recent polls have found that the largest share of Americans support fluoridation, but a sizable minority does not. Polls from Axios/Ipsos and AP-NORC found that 48% and 40% of respondents wanted to keep fluoride in public water supplies, while 29% and 26% supported its removal.

Chelsea Fosse, an expert on oral health policy at the American Academy of Pediatric Dentistry, said she worried that misguided fears of fluoride would cause many people to stop using fluoridated toothpaste and varnish just as Medicaid cuts made it harder to see a dentist.

The combination, she said, could be "devastating."

"It will be visibly apparent what this does to the prevalence of tooth decay," Fosse said. "If we get rid of water fluoridation, if we make Medicaid cuts, and if we don't support providers in locating and serving the highest-need populations, I truly don't know what we will do."

Multiple peer-reviewed studies have shown what ending water fluoridation could look like. In the past few years, studies of cities in Alaska and Canada have shown that communities that stopped fluoridation saw significant increases in children's cavities when compared with similar cities that did not. A 2024 study from Israel reported a "two-fold increase" in dental treatments for kids within five years after the country stopped fluoridating in 2014.

Despite the benefits of fluoridation, it has been fiercely opposed by some since its inception, said Catherine Hayes, a Harvard dental expert who advises the American Dental Association on fluoride and has studied its use for three decades.

Fluoridation was initially smeared as a communist plot against America, Hayes said, and then later fears arose of possible links to cancer, which were refuted through extensive scientific research. In the '80s, hysteria fueled fears of fluoride causing AIDS, which was "ludicrous," Hayes said.

More recently, the anti-fluoride movement seized on international research that suggests high levels of fluoride can hinder children's brain development and has been boosted by high-profile legal and political victories.

Last August, a hotly debated report from the National Institutes of Health's National Toxicology Program found "with moderate confidence" that exposure to levels of fluoride that are higher than what is present in American drinking water is associated with lower IQ in children. The report was based on an analysis of 74 studies conducted in other countries, most of which were considered "low quality" and involved exposure of at least 1.5 milligrams of fluoride per liter of water - or more than twice the U.S. recommendation - according to the program.

The following month, in a long-simmering lawsuit filed by fluoride opponents, a federal judge in California said the possible link between fluoride and lowered IQ was too risky to ignore, then ordered the federal Environmental Protection Agency to take nonspecified steps to lower that risk. The EPA started to appeal this ruling in the final days of the Biden administration, but the Trump administration could reverse course.

The EPA and Department of Justice declined to comment. The White House and Department of Health and Human Services did not respond to questions about fluoride.

Despite the National Toxicology Program's report, Hayes said, no association has been shown to date between lowered IQ and the amount of fluoride actually present in most Americans' water. The court ruling may prompt additional research conducted in the U.S., Hayes said, which she hoped would finally put the campaign against fluoride to rest.

"It's one of the great mysteries of my career, what sustains it," Hayes said. "What concerns me is that there's some belief amongst some members of the public - and some of our policymakers - that there is some truth to this."

Not all experts were so dismissive of the toxicology program's report. Bruce Lanphear, a children's health researcher at Simon Fraser University in British Columbia, published an editorial in January that said the findings should prompt health organizations "to reassess the risks and benefits of fluoride, particularly for pregnant women and infants."

"The people who are proposing fluoridation need to now prove it's safe," Lanphear told NPR in January. "That's what this study does. It shifts the burden of proof - or it should."

Cities and States Rethink Fluoride

At least 14 states so far this year have considered or are considering bills that would lift fluoride mandates or prohibit fluoride in drinking water altogether. In February, Utah lawmakers passed the nation's first ban, which Republican Gov. Spencer Cox told ABC4 Utah he intends to sign. And both Florida Surgeon General Joseph Ladapo and Texas Agriculture Commissioner Sid Miller have called for their respective states to end fluoridation.

"I don't want Big Brother telling me what to do," Miller told The Dallas Morning News in February. "Government has forced this on us for too long."

Additionally, dozens of cities and counties have decided to stop fluoridation in the past six months - including at least 16 communities in Florida with a combined population of more than 1.6 million - according to news reports and the Fluoride Action Network, an anti-fluoride group.

Stuart Cooper, executive director of that group, said the movement's unprecedented momentum would be further supercharged if Kennedy and the Trump administration follow through on a recommendation against fluoride.

Cooper predicted that most U.S. communities will have stopped fluoridating within years.

"I think what you are seeing in Florida, where every community is falling like dominoes, is going to now happen in the United States," he said. "I think we're seeing the absolute end of it."

If Cooper's prediction is right, Hayes said, widespread decay would be visible within years. Kids' teeth will rot in their mouths, she said, even though "we know how to completely prevent it."

"It's unnecessary pain and suffering," Hayes said. "If you go into any children's hospital across this country, you'll see a waiting list of kids to get into the operating room to get their teeth fixed because they have severe decay because they haven't had access to either fluoridated water or other types of fluoride. Unfortunately, that's just going to get worse."


Brett Kelman wrote this story for KFF Health News.


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