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.

As Congress heads back to work after the August recess, advocates for the nation's safety net Community Health Centers are urging lawmakers to end Big Pharma's roadblock on discounted medicines through a federal program known as 340B.

Donald Moore, CEO of Pueblo Community Health Center, said by denying discounts, drug companies are withholding critical resources to help centers serve a growing number of patients who cannot afford to pay.

"That $1.5 million now is staying in their pockets," Moore pointed out. "It's not going into my organization's charitable mission to provide access to care."

The roadblock comes as more Coloradans, who have been dropped from Medicaid coverage, turn to centers serving all patients regardless of their ability to pay. Drugmakers have claimed discounted medicines are being diverted to patients not eligible under 340B, or savings are not being used to expand access to health care.

Justin Hanel, director of pharmacy for Valley Wide Health Systems, which serves southern Colorado, said even with discounts, drug prices have gone up by 200% over the past five years. He emphasized all patients filling Valley Wide prescriptions are eligible under 340B, even if they get them at their contracted pharmacies making it easier for people living in remote areas to access medicines.

"The intent was so that it would enable entities like ourselves to stretch scarce federal resources as far as possible," Hanel explained. "Reach more eligible patients and provide more services."

Moore pointed to a third-party audit, which showed his center is in full compliance with 340B but he said no one has asked to see his books. He said denying discounts nationwide will ultimately end up hurting patients, and taxpayers, if people with chronic conditions such as diabetes, hypertension or depression cannot access medicines.

"Someone who doesn't have access to the medicines they need to control chronic conditions is at greater risk of going to the ER, being admitted to the hospital, and having complications associated with that," Moore emphasized.



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By Tony Leys for KFF Health News.
Broadcast version by Mark Moran for Iowa News Service reporting for the KFF Health News-Public News Service Collaboration

Rural regions like the one surrounding this southern Iowa town used to have a lot more babies, and many more places to give birth to them.

At least 41 Iowa hospitals have shuttered their labor and delivery units since 2000. Those facilities, representing about a third of all Iowa hospitals, are located mostly in rural areas where birth numbers have plummeted. In some Iowa counties, annual numbers of births have fallen by three-quarters since the height of the baby boom in the 1950s and ’60s, when many rural hospitals were built or expanded, state and federal records show.

Similar trends are playing out nationwide, as hospitals struggle to maintain staff and facilities to safely handle dwindling numbers of births. More than half of rural U.S. hospitals now lack the service.

“People just aren’t having as many kids,” said Addie Comegys, who lives in southern Iowa and has regularly traveled 45 minutes each way for prenatal checkups at Oskaloosa’s hospital this summer. Her mother had six children, starting in the 1980s, when big families didn’t seem so rare.

“Now, if you have three kids, people are like, ‘Oh my gosh, are you ever going to stop?’” said Comegys, 29, who is expecting her second child in late August.

These days, many Americans choose to have small families or no children at all. Modern birth control methods help make such decisions stick. The trend is amplified in small towns when young adults move away, taking any childbearing potential with them.

Hospital leaders who close obstetrics units often cite declining birth numbers, along with staffing challenges and financial losses. The closures can be a particular challenge for pregnant women who lack the reliable transportation and flexible schedules needed to travel long distances for prenatal care and birthing services.

The baby boom peaked in 1957, when about 4.3 million children were born in the United States. The annual number of births dropped below 3.7 million by 2022, even though the overall U.S. population nearly doubled over that same period.

West Virginia has seen the steepest decline in births, a 62% drop in those 65 years, according to federal data. Iowa’s births dropped 43% over that period. Of the state’s 99 counties, just four — all urban or suburban — recorded more births.

Births have increased in only 13 states since 1957. Most of them, such as Arizona, California, Florida, and Nevada, are places that have attracted waves of newcomers from other states and countries. But even those states have had obstetrics units close in rural areas.

In Iowa, Oskaloosa’s hospital has bucked the trend and kept its labor and delivery unit open, partly by pulling in patients from 14 other counties. Last year, the hospital even managed the rare feat of recruiting two obstetrician-gynecologists to expand its services.

The publicly owned hospital, called Mahaska Health, expects to deliver 250 babies this year, up from about 160 in previous years, CEO Kevin DeRonde said.

“It’s an essential service, and we needed to keep it going and grow it,” DeRonde said.

Many of the U.S. hospitals that are now dropping obstetrics units were built or expanded in the mid-1900s, when America went on a rural-hospital building spree, thanks to federal funding from the Hill-Burton Act.

“It was an amazing program,” said Brock Slabach, chief operations officer for the National Rural Health Association. “Basically, if you were a county that wanted a hospital, they gave you the money.”

Slabach said that in addition to declining birth numbers, obstetrics units are experiencing a drop in occupancy because most patients go home after a night or two. In the past, patients typically spent several days in the hospital after giving birth.

Dwindling caseloads can raise safety concerns for obstetrics units.

A study published in JAMA in 2023 found that women were more likely to suffer serious complications if they gave birth in rural hospitals that handled 110 or fewer births a year. The authors said they didn’t support closing low-volume units, because that could lead more women to have complications related to traveling for care. Instead, they recommended improving training and coordination among rural health providers.

Stephanie Radke, a University of Iowa obstetrics and gynecology professor who studies access to birthing services, said it is almost inevitable that when rural birth numbers plunge, some obstetrics units will close. “We talk about that as a bad event, but we don’t really talk about why it happens,” she said.

Radke said maintaining a set number of obstetrics units is less important than ensuring good care for pregnant women and their babies. It’s difficult to maintain quality of care when the staff doesn’t consistently practice deliveries, she said, but it is hard to define that line. “What is realistic?” she said. “I don’t think a unit should be open that only delivers 50 babies a year.”

In some cases, she said, hospitals near each other have consolidated obstetrics units, pooling their resources into one program that has enough staffers and handles sufficient cases. “You’re not always really creating a care desert when that happens,” she said.

The decline in births has accelerated in many areas in recent years. Kenneth Johnson, a sociology professor and demographer at the University of New Hampshire, said it is understandable that many rural hospitals have closed obstetrics units. “I’m actually surprised some of them have lasted as long as they have,” he said.

Johnson said rural areas that have seen the steepest population declines tend to be far from cities and lack recreational attractions, such as mountains or large bodies of water. Some have avoided population losses by attracting immigrant workers, who tend to have larger families in the first generation or two after they move to the U.S., he said.

Katy Kozhimannil, a University of Minnesota health policy professor who studies rural issues, said declining birth numbers and obstetric unit closures can create a vicious cycle. Fewer babies being born in a region can lead a birthing unit to shutter. Then the loss of such a unit can discourage young people from moving to the area, driving birth numbers even lower.

In many regions, people with private insurance, flexible schedules, and reliable transportation choose to travel to larger hospitals for their prenatal care and to give birth, Kozhimannil said. That leaves rural hospitals with a larger proportion of patients on Medicaid, a public program that pays about half what private insurance pays for the same services, she said.

Iowa ranks near the bottom of all states for obstetrician-gynecologists per capita. But Oskaloosa’s hospital hit the jackpot last year, when it recruited Taylar Swartz and Garth Summers, a married couple who both recently finished their obstetrics training. Swartz grew up in the area, and she wanted to return to serve women there.

She hopes the number of obstetrics units will level off after the wave of closures. “It's not even just for delivery, but we need access just to women's health care in general,” she said. “I would love to see women's health care be at the forefront of our government's mind.”

Swartz noted that the state has only one obstetrics training program, which is at the University of Iowa. She said she and her husband plan to help spark interest in rural obstetrics by hosting University of Iowa residency rotations at the Oskaloosa hospital.

Comegys, a patient of Swartz’s, could have chosen a hospital birthing center closer to her home, but she wasn’t confident in its quality. Other hospitals in her region had shuttered their obstetrics units. She is grateful to have a flexible job, a reliable car, and a supportive family, so she can travel to Oskaloosa for checkups and to give birth there. She knows many other women are not so lucky, and she worries other obstetrics units are at risk.

“It’s sad, but I could see more closing,” she said.


Tony Leys wrote this story for KFF Health News.


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LGBTQ+ Americans are twice as likely to experience discrimination in health care, including as they age, according to a new survey from the Kaiser Family Foundation.

Now, a nonprofit advocacy group called Sage has created the LGBTQ+ LGBTQ+ Advance Care Planning Toolkit.

Eliza Giles, a nurse practitioner specializing in geriatric care, created the online resource.

"The toolkit is an A to Z guide on conversations, documentation and considerations if you're well, or if you have a serious illness and want access to caregiver resources, advice about palliative care," Giles outlined.

The toolkit explains how to appoint a health care proxy who can visit you in the hospital and make medical decisions if you are incapacitated. The site also helps people spell out their wishes on caregivers, hospice and palliative care and funeral or memorial arrangements.

Osha Towers, LGBTQ+ engagement director for the nonprofit Compassion & Choices, said without advance planning, end-of-life decisions can bypass people closest to you and fall to family members who may have had little to no contact for years.

"There's plenty of us that have gone to funerals with people that don't look like they looked as they live their lives," Towers noted. "Because their family decided to make the choice that they want to erase that part of their identity."

The toolkit also covers estate planning, creating a will, and organ donation.