Nursing homes in New Jersey and nationwide could lose millions of dollars in federal funding if more of their workers don’t get vaccinated against COVID-19, according to a plan outlined by President Joe Biden last week. National regulators are now drafting emergency regulations to require full staff immunization.

Leaders in New Jersey’s long-term care industry welcomed the concept of a federal vaccination mandate in addition to the existing state requirement that health care workers be immunized or regularly tested, although some said withholding funding was not the right way to increase vaccination.

The leader of the state’s largest health-care workers union — which has opposed outright vaccination mandates — offered more nuanced support.

“All healthcare workers have shown enormous courage and made great sacrifices to care for patients, including nursing home residents, on the frontline of this rapidly mutating virus,” Debbie White, a nurse and president of the Health Professionals and Allied Employees, or HPAE, the largest health care union in the state, said in a statement.

“A vaccine is prohibitive for some people,” she said. “Those workers who could get the vaccines have mostly done so and we, as a union, are working with our employers to implement government mandates.”

While more than nine out of 10 long-term care residents in New Jersey have been immunized against the coronavirus, vaccinations lag some among staff, although the numbers are rising. Nearly 74% of these workers have completed their COVID-19 shots, according to state data, up from less than 72% in late July and 56% at the end of April. Nationwide, 62% of long-term care staff have been immunized, federal data shows, but it ranges from 44% to 88% depending on the state.

Withhold federal funds?

Biden announced Wednesday his intention to withhold Medicare and Medicaid funding from nursing homes that do not require staff to be vaccinated. The federal Centers for Medicare and Medicaid Services is now drafting emergency regulations to codify the plan, which would apply to more than 15,000 facilities nationwide. Most of New Jersey’s 365 nursing homes participate in these funding programs, which provide hundreds of millions of dollars annually to support the care for two out of three residents in such facilities in New Jersey.

“As we see the spread of delta and the threat of COVID cases, it is really especially important that we ensure that those caring for our most vulnerable are vaccinated,” Carole Johnson, a senior official on the White House’s COVID-19 response team — and former New Jersey Department of Human Services commissioner — told CNN in an interview.

With few details available, it is not clear if the federal mandate would be absolute or would offer a testing option, like the requirement Gov. Phil Murphy enacted earlier this month. Under Murphy’s order, health and elder-care and corrections workers must provide proof of vaccination by Sept. 6 or submit to COVID-19 screenings at least once a week. Biden issued a similar “vaccinate or test” order for federal workers in late July. A number of hospital systems in New Jersey have opted instead for strict mandates, firing workers who do not get immunized.

The announcement of the federal mandate for nursing home workers came the same day the president announced a new national booster-shot strategy that calls for adults immunized with Pfizer or Moderna vaccines to receive another inoculation some eight months after they finished the initial protocol. U.S. Department of Health and Human Services officials said the department is still studying data on the single-shot Johnson & Johnson formula, but a second, or booster shot, is likely to be recommended for that vaccine as well.

Health officials stressed that the vaccines remain highly effective against hospitalization and death, but the growth of the highly transmissible delta variant of the virus — which now accounts for nine out of 10 COVID-19 cases nationwide — has led to an increase in breakthrough cases, or infections among those who are fully immunized.

NJ nursing homes among hardest-hit

Nursing homes were hard-hit during the pandemic, not least in New Jersey, where facilities had among the highest death rates nationwide in the spring of 2020. Despite strict lockdowns and other infection-control measures, nearly 35,000 COVID-19 cases have been detected among residents and staff at these sites and almost 8,500 died, state records show.

Stephen Crystal, a research professor at Rutgers University School of Social Work who is an expert on aging and health care policy, said the president’s announcement is needed given what he called the “inadequate rates” of staff vaccination in long-term care facilities currently. But he said he was bothered by the vagueness of the timetable for implementing the policy.

“This is a fundamental patient safety issue and needs to be address quickly rather than ‘with all deliberate speed.’ The emergency [regulations] need to be issued immediately as this is indeed an emergency,” Crystal said in an email. “We need to have strong standards for facilities to provide safe care (which includes a vaccinated staff and adequate staffing) and hold facilities accountable for providing them,” he added, “and we need to be willing to pay for this.”

In addition, Crystal would like to see any federal vaccination requirement extended to include other health care workers — including home-care providers who may attend to individuals when they return to their residence after a stay in a nursing home — to better protect vulnerable people. White, with HPAE, and several industry representatives in New Jersey also agreed there is a need for a broader immunization requirement.

“The vulnerable residents of long-term care centers receive care in other healthcare settings including hospitals and physician’s offices, making it essential that vaccination of all healthcare workers be considered as a priority,” Andrew Aronson, president and CEO of the Health Care Association of New Jersey, which represents long-term care facilities of all kinds, said in an email.

‘Not the right way’

Both the health care association and LeadingAge, which represents nonprofit nursing homes nationwide, have urged facility operators to encourage or require vaccination among staff. Access to vaccines has been an essential factor driving down the infection rate at these facilities, the organizations noted. White and other labor leaders note that immunizations are only one part of a broader infection-control protocol, something state officials recently required nursing homes in New Jersey to update.

While supporting vaccination mandates generally, LeadingAge took issue with Biden’s enforcement option, which they said is “not the right way” to increase immunization rates. “Without Medicaid and Medicare funding, nursing homes cannot provide the quality care that our nation’s most vulnerable older adults need. Our mission-driven nursing home members, who operate on narrow margins in the best of times, depend on those funds alone to care for their residents. They cannot bear additional financial losses after more than a year of shouldering historic COVID-related costs,” LeadingAge wrote.

Several nursing homes in New Jersey have shut down this year, a development they attribute to long-standing cash flow problems and the additional costs and requirements imposed by regulators in response to COVID-19. Several experts have said this is likely a trend that will grow in the months and years to come.

New Jersey has some of the lowest Medicaid reimbursement rates in the nation and nursing homes collect slightly more than $220 per diem for each resident covered by the program, which results in daily losses of roughly $40 per person, according to industry leaders.

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