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stephenmccull · 4 years ago

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‘Is This Worth My Life?’: Traveling Health Workers Decry COVID Care Conditions

This story also ran on The Guardian. It can be republished for free.

David Joel Perea called from Maine, Vermont, Minnesota and, ultimately, Nevada, always with the same request: “Mom, can you send tamales?” Dominga Perea would ship them overnight.

That’s how she knew where her 35-year-old son was.

The traveling nurse had “a tremendous work ethic,” routinely putting in 80 hours a week, said his brother, Daniel.

But when Perea took a job at Lakeside Health & Wellness Suites — a Reno nursing home that has received dozens of safety citations since 2017 from the Centers for Medicare & Medicaid Services — Dominga was “scared silly.”

During Perea’s stint, nearly one-fifth of Lakeside’s residents were infected with COVID-19, according to state health records. Lakeside’s “top priority is the safety of those who live and work in our facility,” a spokesperson said.

When her son didn’t respond to her text on April 6, Dominga knew something was wrong. Perea had COVID-19. He died days later.

As COVID-19 surges across the country, health care systems continue to suffer critical shortages, especially among non-physician staff such as nurses, X-ray technicians and respiratory therapists.

To replenish their ranks, facilities have relied on “travelers” like Perea. Staff agencies have deployed tens of thousands nationally since March outbreaks in the Northeast.

Now the virus is tearing through rural areas — particularly in the Great Plains and Rocky Mountain states — stressing the limited medical infrastructure.

Rural hospitals have relied largely on traveling nurses to fill staffing shortages that existed even before the pandemic, said Tim Blasl, president of the North Dakota Hospital Association. “They find staff for you, but it’s really expensive labor,” he said. “Our hospitals are willing to invest so the people of North Dakota get care.”

The arrangement presents risks for travelers and their patients. Personnel ping-ponging between overwhelmed cities and underserved towns could introduce infections. As contractors, travelers sometimes feel tensions their full-time colleagues do not. Frequently employed by staffing agencies based thousands of miles away, they can find themselves working in crisis without advocates or adequate safety equipment.

In 2020, the upsides of their jobs — freedom and flexibility — have been dwarfed by treacherous conditions. Now the ranks of travelers are thinning: The work is exhausting, bruising and dangerous. Thousands of front-line health workers have gotten the virus and hundreds have died, according to reporting by KHN and The Guardian.

On April 17, Lois Twum, a 23-year-old traveling nurse from New Orleans, was one of four passengers on a flight to New York’s John F. Kennedy Airport.

When the self-described “adventure-seeking adrenaline junkie” arrived for her first shift at Columbia University’s Irving Medical Center, she said, she was assigned four patients on a COVID-19 unit. (Intensive care nurses typically care for two or three patients.) As these “constantly crashing” patients required resuscitations and intubations, “there was practically no one to help,” Twum said, because “everyone’s patient was critical.” The hospital did not respond to requests for comment on the workplace conditions and treatment of travelers.

Meanwhile, as hospital employees got sick, quit or were furloughed amid budget cuts, travelers picked up the slack. They were redeployed, Twum said, assigned more patients as well as the sickest ones.

“It was like we were airdropped into Iraq,” Twum said. “Travelers, we got the worst of it.”

On social media and in email groups, recruiters for travelers circulate photos of sun-splashed skylines or coastlines emblazoned with dollar signs, boasting salaries two or three times those of staff nurses. They promise signing bonuses, relocation bonuses and referral bonuses. They make small talk, ask about travelers’ families and suggest restaurants in new cities.

But when it comes to navigating workplace issues, “these people can just disappear on you,” said Anna Skinner, a respiratory therapist who has traveled for over a decade. “They are not your friends.”

Caught between the hospitals where they report for duty and remote staffing agencies, their worker protections are blurred.

For instance, under the Occupational Safety and Health Act, providing protective equipment is the agency’s responsibility — but the travelers who spoke with KHN said agencies rarely distribute any.

Perea’s family said they believe David did not have adequate PPE. His employer said it was the nursing home’s responsibility to provide it. “It is up to each of our clients to provide PPE to our staff while they are working assignments through MAS,” said Sara Moore, a spokesperson for Perea’s agency, MAS Medical Staffing.

Sometimes travelers are assigned to emergency rooms or intensive care units with which they have little experience. Skinner, a pediatric specialist, said she landed in adult ICUs when deployed to the University of Miami Health System in April. She received an hour of orientation, she said, but “nothing could have prepared me for what I had to deal with.”

Over five weeks, she said, she intubated one patient after another; suctioned the blood pouring into patients’ lungs and out of their noses and mouths; and dealt with families who were aghast, angry and afraid. Under the stress, Skinner said, she couldn’t sleep and lost weight. The hospital did not respond to requests for comment on workplace conditions for travelers.

Travelers often face “incredibly onerous” hurdles to the overtime, sick leave or workers’ compensation they are entitled to under the Fair Labor Standards Act, said Nathan Piller, a lawyer at Schneider Wallace Cottrell Konecky, an employment and business litigation firm.

Even the number of hours they can count on working is out of their control, Skinner said. Contracts reviewed by KHN authorize travelers to work a set number of hours, but only a fraction of those hours are guaranteed, and must be approved by on-site managers. The guaranteed hours may be compensated at rates hovering around minimum wage, and may require working holidays, which are not uniformly recognized.

The terms can be “modified from time to time during employment,” according to the contracts.

In 2018, AMN Healthcare, one of the country’s largest travel nursing agencies, agreed to a $20 million settlement for wage violations involving nearly 9,000 travelers. Violations “appear fairly commonplace across the industry,” said Piller, who worked on the settlement.

Travelers, Skinner said, are left to advocate for themselves to managers they might have just met — and “complaining just isn’t an option.”

KHN reviewed travel nursing contracts issued by Aya Healthcare, a large staffing agency, and found that any disputes — wrongful termination claims; claims of discrimination, harassment or retaliation; wage claims; and claims for violation of federal, state or other laws or regulations — must be settled out of court, in arbitration.

Officials at the Service Employees International Union, the American Nurses Association and National Nurses United said their constituents have been suspended or fired from traveling worker agencies for speaking to the news media, posting on social media or otherwise voicing concerns about unfair practices.

Matthew Wall, a longtime traveling nurse, knows this all too well. In July, two days into his assignment at Piedmont Henry Hospital in Stockbridge, Georgia, Wall said, he reported to hospital administrators “undeniably unsafe” conditions for himself and patients, including inadequate PPE, long hours and high patient-to-staff ratios.

Instead of addressing his concerns, Wall said, the hospital — which is under investigation by the federal government for workplace safety issues after another traveling nurse died of COVID-19 in mid-March — canceled his contract. “Travelers are treated like dog chow,” Wall said. “The second you become a liability, they dispose of you.”

“We continue to closely follow Centers for Disease Control and Prevention guidelines paired with our best practices in patient care and safety for all,” said John Manasso, a hospital spokesperson, who declined to comment on Wall’s case.

Some see an impossible choice. “We all know, if not for us, these patients would have no one,” Twum said, “but watching each other get sick left and right, it makes you wonder, is this worth my life?”

Skinner, for her part, took a job as a staff nurse in Aspen, Colorado. After his current contract in New Orleans ends, Wall is planning a break from nursing.

It was like we were airdropped into Iraq.

Lois Twum

Dominga Perea finally received a text back the night of April 6: “Don’t panic, Mama, I have the COVID.

“Pray for me.”

She saw David over FaceTime on Easter. “He struggled even eating mashed potatoes” she said, “because he couldn’t breathe.” The next morning he went on a ventilator and never woke up.

Months later, Lakeside hadn’t filled Perea’s position. “Ideal candidate must be a caring individual dedicated to providing high quality care,” the job listing read, and “able to react to emergency situations appropriately when required.”

KHN Mountain States editor Matt Volz contributed to this report.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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gordonwilliamsweb · 4 years ago

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‘Is This Worth My Life?’: Traveling Health Workers Decry COVID Care Conditions

This story also ran on The Guardian. It can be republished for free.

David Joel Perea called from Maine, Vermont, Minnesota and, ultimately, Nevada, always with the same request: “Mom, can you send tamales?” Dominga Perea would ship them overnight.

That’s how she knew where her 35-year-old son was.

The traveling nurse had “a tremendous work ethic,” routinely putting in 80 hours a week, said his brother, Daniel.

When her son didn’t respond to her text on April 6, Dominga knew something was wrong. Perea had COVID-19. He died days later.

As COVID-19 surges across the country, health care systems continue to suffer critical shortages, especially among non-physician staff such as nurses, X-ray technicians and respiratory therapists.

To replenish their ranks, facilities have relied on “travelers” like Perea. Staff agencies have deployed tens of thousands nationally since March outbreaks in the Northeast.

Now the virus is tearing through rural areas — particularly in the Great Plains and Rocky Mountain states — stressing the limited medical infrastructure.

On April 17, Lois Twum, a 23-year-old traveling nurse from New Orleans, was one of four passengers on a flight to New York’s John F. Kennedy Airport.

“It was like we were airdropped into Iraq,” Twum said. “Travelers, we got the worst of it.”

Caught between the hospitals where they report for duty and remote staffing agencies, their worker protections are blurred.

The terms can be “modified from time to time during employment,” according to the contracts.

Travelers, Skinner said, are left to advocate for themselves to managers they might have just met — and “complaining just isn’t an option.”

Skinner, for her part, took a job as a staff nurse in Aspen, Colorado. After his current contract in New Orleans ends, Wall is planning a break from nursing.

It was like we were airdropped into Iraq.

Lois Twum

Dominga Perea finally received a text back the night of April 6: “Don’t panic, Mama, I have the COVID.

“Pray for me.”

She saw David over FaceTime on Easter. “He struggled even eating mashed potatoes” she said, “because he couldn’t breathe.” The next morning he went on a ventilator and never woke up.

KHN Mountain States editor Matt Volz contributed to this report.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

USE OUR CONTENT

This story can be republished for free (details).

‘Is This Worth My Life?’: Traveling Health Workers Decry COVID Care Conditions published first on https://nootropicspowdersupplier.tumblr.com/

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dinafbrownil · 4 years ago

Text

‘Is This Worth My Life?’: Traveling Health Workers Decry COVID Care Conditions

This story also ran on The Guardian. It can be republished for free.

David Joel Perea called from Maine, Vermont, Minnesota and, ultimately, Nevada, always with the same request: “Mom, can you send tamales?” Dominga Perea would ship them overnight.

That’s how she knew where her 35-year-old son was.

The traveling nurse had “a tremendous work ethic,” routinely putting in 80 hours a week, said his brother, Daniel.

When her son didn’t respond to her text on April 6, Dominga knew something was wrong. Perea had COVID-19. He died days later.

As COVID-19 surges across the country, health care systems continue to suffer critical shortages, especially among non-physician staff such as nurses, X-ray technicians and respiratory therapists.

To replenish their ranks, facilities have relied on “travelers” like Perea. Staff agencies have deployed tens of thousands nationally since March outbreaks in the Northeast.

Now the virus is tearing through rural areas — particularly in the Great Plains and Rocky Mountain states — stressing the limited medical infrastructure.

On April 17, Lois Twum, a 23-year-old traveling nurse from New Orleans, was one of four passengers on a flight to New York’s John F. Kennedy Airport.

“It was like we were airdropped into Iraq,” Twum said. “Travelers, we got the worst of it.”

Caught between the hospitals where they report for duty and remote staffing agencies, their worker protections are blurred.

The terms can be “modified from time to time during employment,” according to the contracts.

Travelers, Skinner said, are left to advocate for themselves to managers they might have just met — and “complaining just isn’t an option.”

Skinner, for her part, took a job as a staff nurse in Aspen, Colorado. After his current contract in New Orleans ends, Wall is planning a break from nursing.

It was like we were airdropped into Iraq.

Lois Twum

Dominga Perea finally received a text back the night of April 6: “Don’t panic, Mama, I have the COVID.

“Pray for me.”

She saw David over FaceTime on Easter. “He struggled even eating mashed potatoes” she said, “because he couldn’t breathe.” The next morning he went on a ventilator and never woke up.

KHN Mountain States editor Matt Volz contributed to this report.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

USE OUR CONTENT

This story can be republished for free (details).

from Updates By Dina https://khn.org/news/article/is-this-worth-my-life-traveling-health-workers-decry-covid-care-conditions/

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thecoroutfitters · 7 years ago

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Here in the United States, we rarely hear much about what’s going on in the rest of the world. Our news media is so focuses on the latest scandal, many of which are of their own creation, that they tend to ignore what’s going on in other countries.

Yet every day, people around the world face crisis and disaster that we don’t hear about.

Such is the situation in Cape Town, South Africa today. There’s a countdown to disaster going on there, as the 3.7 million residents in the area race towards what is being called “day zero.” This is the day when the city runs out of water and it’s currently projected to be May the 11th; just a few short months away.

On that day, the city water authorities will be shutting off water to all but critical installations. People will be forced to get their water from centralized locations, carting it home. A maximum of 25 liters of water (6.75 gallons) per person, per day will be authorized until the day zero crisis is over.

While some people are trying to stockpile bottled water now in preparation, not everyone can do that.

So, what has brought the city to this point? Many say that it has been poor management of the municipal water supply. Accusations of leaky pipes that have not been repaired, poor management of the infrastructure and lack of planning abound.

video first seen on Guardian

But regardless of whether these accusations are true or not, the reservoir that Cape Town depends on for water is down to 26.3% of capacity, after three years of drought.

Government officials are blaming the current water shortages on global warming, which makes a handy scapegoat. But droughts have existed throughout the history of the world, regardless of whether global warming exists or not.

Not developing the necessary infrastructure to survive those droughts is irresponsible on the part of any government, essentially ignoring their responsibility to protect the people they are sworn to serve.

Currently, a massive water conservation campaign is going on in the city, as the residents pull together to extend the date for day zero. So far, this has added four days to the calendar. While that may not seem like much, it is a major victory, one that can be expanded upon.

One news interview of a resident shows how hard people are working to make this campaign work. The man stated that their normal water use was 19,000 liters (5,135 gallons) per month, but that the last month his family only used 8,000 liters (2,162 gallons); a reduction of 58%.

But that probably isn’t going to be enough. Further cuts will have to be made, unless the drought breaks and the reservoir fills once again.

To put that in perspective, the average American uses 80-100 gallons of water per day. So, a family of four would use roughly 12,000 gallons of water per month, more than double what the middle-class South African family uses.

Of course, that interview was of a typical middle-class homeowner. The poor of South Africa, like the poor elsewhere in the world, get by with much less water than that.

Any time people don’t have running water available, and instead have to haul water from the local source, whether a natural source of a government installed community water pipe, they find ways of living on much less water.

I’ve spent time in the villages of Mexico, places where they didn’t have running water. Instead, each family had a water tank out front and the city water truck would come and fill it twice a week. That gave them 100 to 150 gallons of water to last three to four days; roughly 15 gallons per person, per day.

But that’s not the worst. If there is anywhere where people struggle with having enough water it is in sub-Sahara Africa. The norm there is for people to live on five gallons of water per person, per day. That takes care of drinking, cooking and cleaning, including bathing, washing clothes and washing dishes.

Can This Happen Here in the US?

The big question this brings to mind is whether this sort of thing could happen here in the United States. Let’s be honest with ourselves a moment; we’re spoiled. We expect to turn the faucet on and have a virtually unlimited supply of clean, purified water to use.

But that doesn’t mean that it will always be that way. In recent years, we have seen a number of droughts plague various parts of our country. It seems like hardly a year goes by, where there isn’t one part of the country or another which is in drought.

A few years ago, I was in the Colorado Rockies and saw first-hand how low the reservoirs were at that time. Several states depend on the water from those reservoirs, which are filled by the melting winter snow.

Southern California, where a large part of the country’s produce is grown, has seen severe droughts over the last few years, and it is unlikely to get better soon.

Since the area is normally arid, the state has spent billions of dollars over the last few decades, in creating the necessary infrastructure to collect and transport water from the wet northern part of the state for use in farming the southern part.

But politics got in the way of practical reality, and the water which was intended for those farmers was instead flushed down-river to protect the delta smelt, a feed fish.

It is easy to say that this was a situation caused by mismanagement of the available resources. Had the politicians stayed out of the way, the drought would have been manageable and the farmers would have had enough water. But by allowing shaky environmentalism to overcome practical necessity, California’s government has put many of the state’s farmers out of work.

3 Second SEAL Test Will Tell You If You’ll Survive A SHTF Situation

But that’s not the worst situation we face, as far as our water supply is concerned. The scariest piece of data to come forth is that the water level of several of our major aquifers is dropping. We are using the water from those aquifers at a faster rate than it can be replenished.

The aquifers most seriously affected by this are: the Canbrian-Ordavician Aquifer, the High Plains Aquifer and the two aquifers in Southern California.

These are the aquifer that provide water for a large part of the nation’s farming. So, water shortages in those areas means more than just a lack of water, it can lead to shortages in food as well. While water is a higher survival priority than food is, we need both of them to survive.

What Should We Do?

The reality is that you and I are subject to facing the consequences of those who control our water supply, as well as any natural disaster or drought. The economic, technological and military might of the United States can’t do a thing to stop drought. All we can do is prepare for it as best we can.

I don’t care where you live, unless maybe in the Pacific Northwest, rain is not consistent. There are wet spells and dry spells, and just about every resident who has lived anyplace can tell you when they usually are in that area. This is why our country has invested so much in building reservoirs, with over 84,000 dams in the United States.

The reservoirs allow us to have water during the dry spells; but even then, there is a limit to their capacity.

Of course, even if the reservoirs are filled to capacity, that water has to make it from the reservoir to our tap before we can use it. This makes the entire system dependent on electricity, the easiest part of our infrastructure to interrupt.

Blackouts which last more than 12 hours, can be accompanied by a lack of water pressure or even the water shutting off, just because there isn’t power to run the pumps.

The only solution for you and I is to have our own water stockpile. But more than that, we need a means of harvesting water from nature, so that we aren’t totally dependent on the system. That way, if something happens, at least we will have water, even if nobody else does.

This is really the only way we can protect ourselves from ending up standing in line, waiting our turn to get a few gallons of water, like the people of Cape Town. While we will probably still find ourselves having to ration water, at least we’ll have water to ration; and it will be our water, not water that the government can turn off or give away to some bait fish that we’ve never heard of.

There are actually three things we need to do here:

Stockpile water

Develop a means of harvesting water

Have a way of purifying water

I’m not going to get into a detailed discussion about these three areas here, as there are other articles here on Survivopedia which do. But there are a few key things that I want to mention.

Stockpiling Water

Water is difficult to stockpile, simply because of the vast amount of water we need. Since dehydrated water is only a joke, there is no real way of reducing the water’s volume, making it possible to store it in a smaller space. So the question then becomes, where can you find all that space?

I suppose if we all had the money to build an underground cistern or a private water tower, this wouldn’t be an issue. But we don’t; so we need a less-expensive alternative. That’s actually easier to find than you’d expect. All you need is an above-ground swimming pool, which you can buy surprisingly inexpensively.

The chemicals used to keep the water clean for swimming, are the same chemicals that make it safe for drinking.

Harvesting Water

The two basic means of harvesting water are rainwater capture and putting in a well. In both cases, there are legal ramifications that you have to consider, depending on where you live. Some states don’t allow rainwater capture and others limit who can drill a well. So before making a decision on this, you have to see what your state allows.

I’ve never liked the government telling me I can’t do something, especially if that something doesn’t hurt anyone else. So, just as a thought for your consideration, if I lived in a state where they didn’t allow rainwater capture, I’d put it in anyway.

To keep anyone from knowing what I was doing, I’d bury the water barrels, making it look like I had nothing more than a French drain for my downspouts.

New technologies are emerging, which show considerable promise. These focus on extracting moisture from the air. If you live in an area with high enough humidity to have fog, you can build simple fog catchers, which will allow you to convert the moisture in fog into drinkable water.

Other, more complicated technologies allow for extracting moisture from the air, even when there isn’t fog. These are still expensive, as they are new, but prices should drop as they become more readily available.

Purifying Water

Any water you harvest needs to be purified, even rainwater. Birds tend to do things on the roof of our homes, which ensure that the rainwater we capture isn’t as clean as we might expect it to be. So don’t expect that water to be pure, if you haven’t purified it.

Likewise, well water can contain a considerable amount of bacteria, even when it comes from one of the deep aquifers. The only way of being sure that it is safe to drink is to purify it.

But water used for gardening, bathing, cleaning and flushing toilets doesn’t have to be purified. We use purified tap water for that now, just because it is cheaper to do that, than it is to put two water lines into every home, one for purified and one for non-purified water.

Be sure to have more than enough filter cartridges for your water filter, if you are using filtration to purify your water. Even the best cartridges only last so long, so put in a good stock.

Conserving Water

No matter what you do to harvest water from nature, it’s probably not going to be enough, unless you also work to conserve water. The 100 gallons of water, per person, per day, that Americans use, is the highest rate of water consumption in the world.

People in South Africa are given a breakdown of water usage, that comes down to 50 liters per day. That’s a mere 13.5 gallons!

Many survival instructors say that you need one gallon of water per person, per day, for survival. But that’s just taking into consideration the water you need for drinking and cooking. It also doesn’t take into account hot temperatures. If you live in the Southwest, limiting yourself to that quantity of water could cause you to suffer severe dehydration.

Is it possible to live on the 13.5 gallons of water that they are recommending in South Africa? Yes, it is. But it means making some serous adjustments to our lifestyle. Take bathing for example; the average American bathes daily, using from 17 to 36 gallons of water per day.

But people in poorer countries can’t use that much water. Even in Latin American countries where they bathe daily, the average water consumption is much lower, with bathing accounting for only a gallon or two of water per day.

One of our biggest water wasters is flushing the toilet. Older toilets use as much as seven gallons of water per flush, while newer ones can be as low as 1.6 gallons per flush. So, changing out toilets can drastically reduce the water consumption of your family.

The other thing that can reduce it is not flushing every time it is used. Urine is biologically sterile, so unless the urine concentration in the water reaches a point of causing it to smell, there is no reason to flush every time you urinate.

But we have a water user that’s even bigger than toilets; that’s our lawns. With the large lots that we typically have for our homes (based on a world-wide average) and the fact that we all seem to plant lawns, we use an enormous amount of water keeping that grass alive.

To provide your lawn with one inch of imitation rainfall requires 62 gallons of water for every 10’ x 10’ area. So you could easily go through several hundred gallons of water in one day, just by watering your lawn.

I’ve lived in a couple of different arid areas during my life and I remember water rationing. During the rationing, we were only allowed to water our lawns certain days or not at all. When you’re living in a hot climate anyway, not being able to water your lawn could be enough to ensure its death.

So How Should We React?

Potential water shortages, even severe shortages, are no different than anything else that you and I prepare for. Like other potential disasters, the key is to be as self-sufficient as possible. That’s the only real protection for ourselves and our families.

Taking the actions I’ve mentioned above, as well as others you can find in this website, will ensure that you won’t be standing in line for hours, waiting to be able to get your daily ration of a few gallons of water. You and your family will be able to live a much more normal life, even if everyone else is suffering.

That’s not to say that you should flaunt your relative wealth. Part of good OPSEC is living as much like everyone else as possible. If you’re watering your lawn and washing your cars, while everyone else is fighting to have enough water to drink, it will quickly become obvious that you have an abundance of water.

You can expect that to be immediately followed by a line of people forming at your front door, expecting you to share with them.

However, one way of hiding your wealth might be to co-opt your neighbors. If you have enough water to share, then why not share it with them? Allow them to get their water from you, rather than having to go to the water point and stand in line. Just make sure you know how much water you are able to produce and how much you can afford to give them.

Sharing your water with your neighbors could act to help protect you, as they would have a vested interest in your source of water remaining a secret. That has some real tactical advantages, especially since it will be much easier to co-opt their cooperation, than trying to hide what you’re doing from them.

Unless your OPSEC is perfect, you have to assume that your neighbors at least have some idea of what you’re doing.

Finally, whatever you do, don’t panic. Panicking will just make it more difficult to survive. Nobody can think clearly when they are in panic mode. But there’s really no reason for you to panic. You’re the one who knows what to do and has prepared to do it.

So, while everyone else is worried about how they’re going to survive, you don’t have to worry. All you have to do is put your plans into action and keep going forward. You’ll be all right.

This article has been written by Bill White for Survivopedia.

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ihhc · 5 years ago

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Bad Death Or Good Death: End-of-life Care In India

Forty-two years ago, a nurse working at the King Edward Memorial (KEM) hospital was thrown into a permanently vegetative state because of a sexual assault. She survived in that state for just over four decades, then died naturally. The Aruna Shanbaug case brought to light the limits of the lawas related to end-of-life care, which are really at aembryonic stage in India.

Our courts did give guidelines differentiating between active and passive euthanasia, holding the latter to be legally permissible. This was challenged in the case of Common Cause versus Union of India, which held that the decision on Shanbaug was based on a wrong interpretation of the Gian Kaur case, in which a constitution bench had held that right to life did not include the right to die.

What it really boils down to is this: How do we determine death? In order to legislate on end-of-life, the essential question that needs to be answered is – when can a person be considered dead? Is it when the heart stops functioning, or the brain, or the lungs? The advances in medical technology have made death more of a process, rather than a precise point. Unfortunately, under existing Indian law, the parameters for determining death in certain cases depends on whether or not an individual is donating his or her organs.

Meeting Death With Dignity And Grace

According to a story published in Livemint.com (October2016) Nagaraj (name changed), a 32-year-old man suffering from oral cancer, was brought to Karunashraya, a hospice for end-of-life cancer patients in Marathahalli, Bengaluru. In her early morning shift, his nurse greetedNagaraj and checked his wound which was cleaned just an hour before she came on duty. But due to the discharge from the wound on his cheek which extends right up to his neck, his mouth needed to be cleansed again and the wound needed another dressing. While she checked his diaper, and turned him on his side, his nurse wondered what Nagaraj’s life would have been before he was brought into the hospice.

At the time this case was recorded, Karunashraya had 53 occupants with four new admissions on that day. The same day three residents had passed away. The outflow was as quick as the influx at this 80-bed hospice. Few residents lived more than a fortnight, many died in three to four days. But death and suffering are social levelers, hence patients from wealthy families were also admitted into Karunashraya when their families could no longer cope with their illnesses.

India ranks dreadfully low on palliative care, which has not been integrated into the health care system of the country. In a report commissioned by The Economist in 2016, India ranked 67th out of the 80 countries on the Quality of Death Index. Generally speaking, ignorance of end-of-life-care makes India one of the worst countries to die in.

Falling Back On Spiritual Resources

Palliative care patients use spiritual and religious coping methods when other ways of coping don’t provide comfort. According to Hinduism, good karma leads to good birth and bad karma to bad rebirth. Suffering in this life is explained in terms of past karma. So, in India, there’s a notion of good death and how to die thus while a bad death is greatly feared. Hinduism sees death as transition to another life by reincarnation, or a life in heaven with God or absorption into Brahma.

Those who have taken Sanyas, cut themselves off from material and emotional concerns and get ready for death through prayer and meditation – whatever the suffering involved. But, there is a difference between the consciously willed death of a spiritually advanced person and someone in pain wishing to end an unbearable life. Assumptions or conclusions regarding palliative care, based on a person’s religious status, are misguided. Decisions about method and treatment should be taken on the basis of the way of life, customs, opinions, values, attitudes and monetary resources of individual patients, and not on the basis of a predetermined religiousand cultural construct.

The World Health Organization (WHO) defines palliative care as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual”.

End-of-life Care In India, In The 21st Century

In India, there are approximately 500 centers providing palliative care. The “Kerala Model” is very well accepted in the country. The Neighborhood Network of Palliative Care and “Palliative care in Campus Groups” are part of initiatives where there is community participation.

But, there is no policy at a national level on Palliative and EOL Care. While palliative care is mentioned in the National Cancer Control Program, specific guidelines are lacking with respect to other incurable conditions such as AIDS and end stage chronic medical diseases.

Typically, in the developed world, there are four core values of medical ethics on which palliative care is based:

Autonomy: patient has the right to choose or refuse the treatment

Beneficence: a doctor should act in the best interest of the patient

Non-maleficence: first, do no harm

Justice: distribute health resources equitably

Additionally, two more values enshrined in medical ethics are:

Dignity: the patient and the persons treating the patient have the right to dignity

Truthfulness and honesty: the concept of informed consent and truth telling

The model of palliative care which has evolved in the West around these values is difficult to adhere to in India – considering the current state of palliative care, and the applicable laws, available in India.

Ethics And Customs In Palliative Care

The doctor is protected against litigation and malpractice if acting in the best interest of the patient. The Indian Society of Critical Care Medicine has developed directives to deal with issues of prescribing opioids, such as increased doses of morphine, or switching off life support. The document essentially deals with doctors’ attitude towards severely ill patients in ICU. It also refers to medical practitioners’ objective and subjective assessments, honest and accurate disclosure of prognosis, early option of palliative care in poor prognosis, ensuring consistency among the care giver teams, as well as giving a checklist when to put the patient on EOL care (i.e., withdrawal of life support) within the bounds of law.

In Indian culture, family members and physicians may share decisional duties.Quite often more than one relative is involved in the care of the patient and they would all want to know the clinical details. Language differences between health care professionals and patients create huge barriers in communication. Hence effective communication (and explanation of the disease process) is the key to ethical palliative care. It is a well-known fact, that timely application of palliative care easesdistressing symptoms in terminal stages of diseases and avoids toxicities of questionable therapies.

At present, there is a dissonance between the Fundamental Rights enshrined in Article 21 of the Indian Constitution on the one hand, and the Supreme Court decisions and Indian Penal Code (IPC) sections related to suicide (IPC 309) and abatement of suicide (IPC 306), on the other. However, opinions expressed by lawyers are that if a doctor who withdraws or withholds treatments in good faith is subject to criminal prosecution, there is plenty of room for his defense even under current laws. Mr. S. Balakrishnan, a Supreme Court Lawyer, is unequivocalin his opinion that the best defense for a doctor in a civil suit related to this issue would be to prove that he “has acted in conformity with the standards prevailing in his profession.”

The ongoing case of Common Cause versus Union of India and the pending draft bill are only the beginnings of a journey towards resolving legal issues surrounding end-of-life care and respecting people’s rights to die with dignity. Lawmakers have to draw a line between life and death; we should all hope that it will be dealt with the focus on human dignity in line with the robust laws defending the right to life, under the constitution of India.

Source: India Home Health Care

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jeroldlockettus · 6 years ago

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Why Rent Control Doesn’t Work (Ep. 373)

Caption: In the U.S., median rent has doubled since the 1990’s, outpacing inflation. Politicians and the public think rent control is the solution. Spoiler alert: it’s not. (Photo: Caelie Frampton)

As cities become ever-more expensive, politicians and housing advocates keep calling for rent control. Economists think that’s a terrible idea. They say it helps a small (albeit noisy) group of renters, but keeps overall rents artificially high by disincentivizing new construction. So what happens next?

Listen and subscribe to our podcast at Apple Podcasts, Stitcher, or elsewhere. Below is a transcript of the episode, edited for readability.

For more information on the people and ideas in the episode, see the links at the bottom of this post.

* * *

I’m sure you know this already, but let me say it anyway: cities have become really popular, all over the world. An ever-larger share of the U.S. and global population lives in cities, and that large share is expected to get even larger. As demand for city living grows, the supply of housing often can’t keep up. Which results in — and you know this too — a rise in prices. In the U.S., median rent has doubled since the 1990’s, outpacing inflation by quite a bit. In many cities, this makes it hard for people who already live there to stay, and hard for people who’d like to move there. I’m sure you’ve heard the horror stories about rents in cities like London and Hong Kong; Seattle and San Francisco, where the median one-bedroom apartment costs about $3,700 a month. The problem is so bad in New York City that it inspired a new political party.

Jimmy McMILLAN: I represent the Rent Is Too Damn High Party. People are working eight hours a day and forty hours a week and some a third job.

New York, like many cities, has over time put in place various affordable-housing policies. One time-honored tradition is some form of rent control. That might mean setting a price cap on what a landlord can charge or limiting the amount the rent can be raised. Here’s the Stanford economist Rebecca Diamond.

Rebecca DIAMOND: From an economics point of view, it provides insurance against getting priced out of your neighborhood.

And rent control seems to be having a moment. It already exists in a number of places.

DIAMOND: The most expensive cities in the U.S., they almost all have rent control.

And the appetite is spreading.

DIAMOND: You see rent control popping up politically when housing prices and rents are going up.

Among the cities currently considering some form of rent control are Chicago, Philadelphia, Providence, and Denver. Oregon recently became the first state to pass a rent-control bill. A statewide proposition in California failed, but some cities there are moving ahead on their own. A recent report by a consortium of affordable-housing advocates says that if all the proposed rent-control legislation were to pass, nearly one in three American tenants would have some kind of rent protection.

* * *

Most economists say that rent control is a bad idea, as is just about any form of price control. They believe that markets work best when supply and demand are allowed to find a natural equilibrium, with price acting as the referee. Here’s one such economist.

GLAESER: My name is Ed Glaeser and I am the Fred and Eleanor Glimp professor of economics at Harvard, where I teach both microeconomic theory and the economics of cities.

DUBNER: Ed, you have one minute to convince someone that rent control is a terrible idea. Go.

GLAESER: All right. So, I’ve already squandered five of my seconds. It’s not particularly fair. It’s not a good way of allocating scarce space. It’s not a good way of helping the downtrodden. It’s a way that freezes a city and stops it from adjusting to changes, a way that freezes people in apartments and stops the motion that is inherent in cities.

So that’s a baseline economic take, at least. Let’s try to unravel this issue, starting with a brief history of rent control.

GLAESER: Rent controls really became ubiquitous in World War II, and the idea here was, the nation was laying down its life to try and bring freedom to the world, and it seemed wrong that some people who were well-placed should earn some form of extra bonuses by being able to raise up rents on people, maybe whose sons and daughters were off fighting for the U.S. elsewhere. And rent control was seen as being a way of, somehow or other, trying to keep America being a bit fairer during World War II. Now, lots of places introduced rent control during this period. After the war, most of them got rid of it because that cause seemed to be a little bit less pressing. But, some cities kept it, and New York, of course, is the most famous place that still has it.

Glaeser himself grew up in New York.

GLAESER: I lived in a rent-stabilized unit for the first ten years of my life. I mean something like 72, 74 percent of New York City’s households were renters in those days. And indeed, the mid-1970s was an era in which New York’s housing didn’t seem that expensive, affordability just wasn’t the same issue that it was today. Now, flash forward 30 years, the cities have been enormously successful they haven’t built enough to accommodate the new demand. They risk becoming boutique towns affordable only to the wealthy, and people are desperate to see that those cities don’t push out every poor resident, that they don’t become monocultures built around the privileged and the rich, and rent control appears to be at least one avenue for doing it. But it’s a very blunt instrument.

Just how blunt? There are decades’ worth of economic research describing the downsides of rent control. The first major paper was written in 1946 by Milton Friedman and George Stigler; here’s Friedman:

Milton FRIEDMAN: Rent control is a law that supposedly is passed to help the people who are in housing. And it does help those who are in current housing. But the effect of rent control is to create scarcity, and to make it difficult for other people to get housing.

Where did this scarcity come from? For one, developers had less incentive to build new housing if there was a ceiling placed on what they could charge. Friedman also argued that rent control created a “haphazard and arbitrary allocation of space.” This was echoed in a 1972 paper by Edgar Olsen, which found that rent control led to what economists call an “overconsumption” of housing.

GLAESER Let’s say you rented an apartment in New York in 1955, you had three small kids, you rented a three-bedroom. It was perfectly matched for the needs of you with your kids growing up. They moved out of the house in the early 70’s. By the late 80’s, maybe your husband or wife actually died and you’re living on your own in a three-bedroom apartment in New York. But, my goodness, would you ever move out? Your rent is a fraction of what the market rent is. One of my favorite stories about this — and this is quoted by Ken Auletta’s The Streets Were Paved with Gold, he cites Nat Sherman, the famous tobacconist to the world, who had this big shop on Fifth Avenue, who said that he pays, I forget what it was.

DUBNER: $355 a month for a six-room apartment, it says here.

GLAESER: Isn’t that amazing? Keep in mind, it’s a few decades ago. But it’s an unbelievable deal. Now, what’s outrageous about this is, he then says, “I think it’s fair because I use it so rarely,” right? Which means that he’s not getting very much value out of it, but the crazy thing about this is, there were lots of New Yorkers who would love to have that apartment and it would get a lot more value out of it.

In 1997, Ed Glaeser did his own analysis of rent control in New York City, trying to determine just how economically inefficient it was. He and his co-author, Erzo Luttmer, found that “this misallocation of bedrooms leads to a loss in welfare which could be well over $500 million annually to the consumers of New York, before we even consider the social losses due to undersupply of housing.” Glaeser’s work has also inspired a new generation of economists to further the literature on rent control.

DIAMOND: Historically, people relied much more on theory in making their arguments about rent control.

That’s Rebecca Diamond again. She’s a former student of Ed Glaeser’s.

DIAMOND: Because even without a lot of data you can make some pretty simple theoretical predictions about what rent control might do to a housing market.

But there are some things that theory alone cannot tell you.

DIAMOND: One of the biggest open questions in the literature of rent control is: what happens to those tenants that get rent control? Really, how much are the renters benefiting, because they’re the potential big winners of rent control. And to measure that, you really need to have data on where everybody lives, and who gets access to rent control, and whether they decide to stay in that rent-controlled apartment or go somewhere else. And traditional data sources that economists work with very rarely track migration of an individual.

DUBNER: So you recently co-authored with Tim McQuade and Franklin Qian a paper called “The Effects of Rent Control Expansion on Tenants, Landlords, and Inequality: Evidence from San Francisco.” First, if you would, talk about the data.

DIAMOND: Yeah, we have some really cool data. So, traditional data sets, you can get things on the distribution of earnings and income, things like that. But you won’t also see their migration. So, we have this, you could call, administrative data, which tracks people’s address histories.

DUBNER: And where did these migratory data come from?

DIAMOND: We bought them from a company called Infutor. They are a company that works in “identity management,” So they have this history of addresses for everyone which they collect from a number of different sources and stitch them together, which is very useful for the private sector and firms that need to keep track of up-to-date addresses. But from a research perspective, it’s super-exciting data because it’s so big and so detailed.

Armed with this super-exciting data on individual tenants, Diamond and her fellow researchers set out to measure some of the long-term effects of rent control in San Francisco. They made particular use of a change in the city’s rent laws. San Francisco had rent control, but it didn’t apply many of the city’s smaller apartment buildings.

DIAMOND: And the exemption was basically thought of as, “Well, these are mom-and-pop landlords. They don’t have market power. They’re not corporations. So we don’t need to regulate their rents.” And then newspapers reported that those smaller multi-family buildings were increasingly purchased by corporate entities, because that’s really where you could make your money in the housing market. And that led to a vote in 1994 where everyone in the city got to vote about whether we could remove this small multi-family exemption, and that would then expand rent control, not just to the large multi-family housing stock, but also the small multi-family housing stock. And that, indeed, passed.

DUBNER: So, you’ve got this awesome new law — awesome for you guys, at least, as researchers — that lets you mark before and after. It’s a perfect little natural experiment with a control group. And then you’ve got these wonderful data sets. And then you mash up all of these data together and analyze it and you find the following: your paper concludes that among many things “rent control limits renters’ mobility by 20 percent and lowers displacement from San Francisco, especially for minorities.” So let’s start with this: what does it mean exactly that renters’ mobility is lowered by 20 percent, and why is that important?

DIAMOND: So, we look at whether the renters who get access to rent control choose to remain in their newly rent-controlled apartment. So, we find that they are 20 percent more likely to remain there, relative to our control-group renters who don’t get access to rent control.

DUBNER: So, that seems totally unsurprising, yes?

DIAMOND: Yes, I more see that result as a validation that our data is good and high-quality and we have some something to work with here.

DUBNER: Okay. Further, you write that “rent control lowers displacement from San Francisco.” What does that mean, exactly?

DIAMOND: So, we can look at not just whether you remain in the actual apartment you lived in when you got access to rent control, but whether you remain in San Francisco as a whole. We find rent control has a dramatic impact on whether you actually live in San Francisco or not. So, it prevents those renters from leaving the city as a whole, which I think from a policy perspective of rent-control advocates, that’s one of the goals they talk about as preventing displacement from the city.

DUBNER: And then you write that, especially for minorities, that displacement is lowered.

DIAMOND: Right. So, when you look at that first cohort of renters that already lived in the city at the time of rent control, it is definitely helping minorities more. It’s preventing displacement of them especially.

DUBNER: Furthermore, you write that landlords who are susceptible to rent control “reduce rental housing supplies by 15 percent either by converting to condos, selling to owner-occupants, or redeveloping buildings.” So, now it starts to get a little more complicated. Can you talk about who’s now starting to win here and who’s starting to lose here?

DIAMOND: So, obviously, when the landlord is first notified about rent control, he or she can quickly deduce that his or her rental stream is going to be lower than previously expected. And just like any other business owner, they might think about changing their business strategy. So, if renting out their apartments is no longer very profitable, now they may decide, “Oh, maybe it’s worthwhile to convert to condos and sell off the apartments to owner-occupants” and that would be a way to recover some of this lost income. Or, another thing they could do is, say, knock down their old building and build some new construction and either sell those as condos or rent them out as apartments.

Both of those options would avoid them having to pay this tax of rent control, help recoup some of their losses — which is good for the landlords, but is going to undermine the goals of rent control because now we’re going to have less rental housing out there available for rent control.

So you can start to see how rent control may be accomplishing a narrow, short-term goal — making existing housing more affordable for a select group of people — at the expense of the long-term goal of making a city more affordable generally.

DIAMOND: When you pass rent control, the landlords of the property suddenly getting covered by rent control are losing so much money, they no longer really want to rent their apartments out at the prevailing new prices, so they decrease their supply of rental housing to the market. And if there’s less supply, that’s going to drive up prices.

DUBNER: Okay, so, let me just make sure I have it pretty straight. You find evidence that rent control increases gentrification, one component of which is the displacement of low-income tenants. On the other hand, you also find evidence that low-income people, including minorities — at least those who are in rent-controlled units already — they’re likely to disproportionately benefit from rent control.

So, if I’m an affordable-housing advocate, I might say, “Oh, fine, fancy Stanford professor — who I’m sure has some kind of great income and/or housing subsidy and/or situation — I don’t care that some landlords are suffering. I don’t care that the policy is having some downstream effects that you don’t like. I need to make sure that low-income people aren’t going to get a rent increase of 50 percent overnight.” So, how do you respond to that argument?

DIAMOND: So, when you think about those initial tenants, that’s the best bet you’re going to get for the benefits of rent control to low-income tenants: the people that are already in the housing. But even though we find that those tenants are much more likely to stay in their apartment, when we look 10, 15 years later, the share of those 1994 residents that are still there is down to 10 percent or so. So 90 percent of them no longer live in that initial apartment.

And it’s that next low-income tenant that wants to live in the city, that low-income tenant is going to have a very hard time finding an affordable option, because now there’s going to be less rental housing, the prices that that low-income tenant are going to face when they want to initially move in are going to be higher than they would have been absent rent control.

DUBNER: I’m curious how generalizable you think your findings from San Francisco are for other cities.

DIAMOND: I would suspect that the actual quantitative loss of rental supply or benefits to the tenant will depend a little bit city to city, but I think the qualitative takeaway that landlords are savvy and are going to work hard to not lose money on their investments, I think is a very general point.

For economists who already felt confident in the theoretical arguments against rent control, research like Diamond’s provides empirical evidence that essentially tells the same story. Yes, there are some winners in rent control; but the losing is more widespread, and longer term. But how about empirical evidence from a reverse angle — that is, not when a city adds or expands rent control, like San Francisco did, but when it gets rid of it?

DIAMOND: So, there’s other work by David Autor and coauthors that looks at the removal of rent control in Cambridge, Massachusetts, in 1994.

By the early 1990s, Cambridge was one of the few remaining rent-control strongholds in Massachusetts. Landlords had been trying to get rid of it for years. But there are a lot fewer landlords than there are tenants, so any attempt to change the local law was voted down. Finally, the rent control opponents had a winning idea: put the issue up on a statewide referendum, where there might be less empathy for all those city dwellers with below-market rents. When the referendum was held, nearly 60 percent of the voters in Cambridge were opposed — but, statewide, it passed, and so Cambridge began to deregulate its rents. Years later, a trio of M.I.T. economists examined the effects of removing rent control.

GLAESER: Okay, so, the classic paper on this has been written by David Autor, Parag Pathak, and Chris Palmer.

Ed Glaeser again.

GLAESER: It showed that when units were brought out of rent control, their owners invested in them. So, they upped the quality of the units; there was more of a supply of higher-end housing.

DIAMOND: They find that the rent-controlled apartments experience a lot of renovation. Landlords renovate a lot, and that drives up the desirability of living in those apartments. Also, they find that that creates spillovers onto the nearby apartment buildings that they themselves weren’t rent-controlled.

GLAESER: So neighboring apartments became more valued as a result of the end of rent control. And the most recent paper has shown that crime has gone down — particularly, street crime has gone down right after the elimination of rent control in Cambridge.

DIAMOND: So it looked like rent control had negative externalities on the neighborhood.

So what does economic research tell us about rent control? There are at least two conclusions — which, if I’m reading it right, sort of work against each other. The first conclusion is that rent control doesn’t help many people for very long, in part because it constrains the supply of affordable housing. The second conclusion is that just getting rid of rent control does not, in and of itself, lead to more affordable housing; in fact a deregulated housing market can easily lead to less affordable housing. The Boston-Cambridge area is one of many places experiencing a steep shortage in not just affordable housing but housing overall.

So even if you accept that rent control is a big contributor to the affordable-housing problem, getting rid of it isn’t necessarily a solution. You can see why politicians and policy-makers are confused. In Massachusetts, in fact, there’s currently a movement to bring back statewide rent control. And as we mentioned earlier, Massachusetts is not alone.

DIAMOND: So, we just had this big vote in California about whether we should repeal a statewide law that restricts the scope of rent control in California, and indeed we did not repeal that law.

DUBNER: So, somebody read your paper.

DIAMOND: It was interesting to see how our results were used by policy makers and media on both sides of the fight. Because indeed, some of our results are, like, rent control are good, others make them look bad. You’ve got to read the whole paper and take it all into account to make a decision, but it was a very policy-relevant paper for that discussion.

DUBNER: I’m curious what you can tell us about the political dimensions of rent control. I may be wrong, but I believe that rent control is generally supported by Democrats and generally opposed by Republicans.

DIAMOND: I think it’s a simplification to say all Democrats support rent control. But I think in the short run, you can see the benefits of rent control — the tenants right away benefit. What’s much harder to see are these indirect effects that take a long time, and it’s harder to put your finger on that. The losses are spread everywhere a little bit, and harder to see walking down the street or talking to your constituents.

GLAESER: There certainly are some poor people who can benefit. And, it’s a very tangible benefit, right? It’s not some complicated thing which requires you to trust in the market. It’s just sort of very clear, and if you think that people on the left, many of them just don’t trust markets to begin with, then saying there’s going to be some negative market effect to them, that sounds like capitalist hocus-pocus, whereas, what they can see right now is that Mrs. Reyes’s rents won’t go up because of their regulation.

Vicki BEEN: Economists tend to believe their models and say, “End of story,” and, “Believe me,” right?

That’s Vicki Been.

BEEN: But communities don’t necessarily have to believe economists, and so economists need to do a better job of responding to the very real fears that communities have.

Been used to be commissioner of the New York City Department of Housing Preservation and Development. Now she’s a law professor at New York University, and she directs the Furman Center for Real Estate and Urban Policy.

BEEN: The Furman Center has embarked on a project that we call “Not Your Grandmother’s Rent Control” to try to figure out, if you were starting from scratch, and you were designing the most efficient rent-regulation system, what would that look like?

* * *

As we’ve been hearing, economists are generally opposed to rent control. It rewards some people, but fairly arbitrarily; it punishes many others, and generally doesn’t do much to improve overall access to housing. That said, most people don’t think like economists, or even believe them. Which is why many politicians and members of the public think rent control is a great idea.

David EISENBACH: Well, I’m in favor of residential rent control and rent regulations.

That’s David Eisenbach; he teaches history at Columbia University and he recently ran for a citywide office in New York called public advocate. There are in New York City about 3.4 million apartment units, nearly 1 million of which are rent-stabilized. And New York’s rental market is incredibly expensive — as it is in many other cities with regulated rents, like San Francisco. Economists argue that overall high prices are a direct consequence of rent regulation; what does Eisenbach think?

EISENBACH: I disagree. I mean, there are a lot of reasons why real estate in San Francisco and real estate in New York are high. Blaming it on rent stabilization is definitely not it. The consequences of getting rid of either rent control and/or rent stabilization would be the immediate displacement, of a big portion of the population, and that would just be cruel at this point. I don’t know how anybody could justify — even somebody looking at it purely in economic terms — how anybody could justify that, just in human terms. You’re going to blame the high rents on rent control? Come on.

Okay, so Eisenbach does not believe the economic research on rent control. What does he believe in?

EISENBACH: Well, first and foremost, I’m an angry New Yorker who walks around the streets of New York and sees empty storefront after empty storefront, and just feels like my city is dying.

New York’s commercial rents have spiked along with its residential rents. And in some parts of Manhattan, as much as 20 percent of the retail space is either vacant or soon to be vacant.

EISENBACH: And I found out that there is this bill called the Small Business Jobs Survival Act. It was initially submitted back in the 1980’s and I figured, why don’t I run for office pushing this bill? And so I ran for public advocate on the platform, “We’re going to pass this bill; it’s going to save small business in New York City.”

We should say that Eisenbach did not win the election. He came in 13th in a field of 17. But he did get a fair amount of attention for talking about all those empty storefronts, which have upset a lot of people.

EISENBACH: There are two major provisions of the Small Business Jobs Survival Act. One: it guarantees a 10-year lease renewal offer from the landlord to the tenant for any tenant with a commercial lease in New York City. Number two: if the landlord and tenant cannot come to an agreement, they go to legally binding arbitration, and that arbitrator then will pick a fair market rent, which will then be charged in the next 10-year lease renewal.

Opponents of this proposal call it commercial rent control.

EISENBACH: But this bill, the Small Business Jobs Survival Act, is absolutely not rent control. It doesn’t put a limit on how much rent can be charged, which is the very definition of rent control. It’s legally binding arbitration. Much different.

DUBNER: Are there other cities that have this kind of small-business jobs protection on the real-estate front that works well?

EISENBACH: It’s going to be unique.

Even though Eisenbach lost his election, he still believes the Small Business Jobs Survival Act may get through New York’s City Council. I was interested to know what the economists we’ve been speaking with — Rebecca Diamond of Stanford and Ed Glaeser of Harvard — what they thought about commercial rent regulation.

DIAMOND: So, I’m also very interested in that, and I also know almost nothing about it. I have never seen any work on it.

GLAESER: You can easily tell a story where the threat of some form of rent control makes a vacancy problem worse in the short run. So, for example, I don’t want to rent right now to a lower-end tenant who could fill my space, because I’ll be locked in by the rent-control law and I’ve got that tenant forever. So, that means, I’m going to really hold out for a blue-chip tenant because I have this threat of this law over my shoulder.

So, do I think vacant empty storefronts are a problem? Sure. I mean, we can talk about it from a perspective merely as an urbanist, where we think it’s unattractive to have these things, but I’m also disturbed by it as an economist, because someone’s got space to sell, there are people who want to buy that space. Why isn’t the transaction happening, right? It’s sort of — the market is going awry. And the answer to that — of why the market is going awry — is not immediately obvious.

There are of course plenty of theories as to why so many storefronts in New York are vacant. Here again is Vicki Been, the former housing official who studies the real-estate market at NYU.

BEEN: I think there are a lot of questions about how commercial rent regulation would work and how it might interfere with an efficient market. One concern that I would have right now is, we seem to be in the middle of an upset, of a transition in retail in general, because of the availability of Internet retail. A lot is in flux.

GLAESER: But there are two points of evidence against that. One of which is that many of these storefronts formerly held services, and I don’t think a nail salon has been made obsolete by Amazon just yet. And secondly, the rents, the asking rents, at least according to the most recent Real Estate Board of New York report, in many of these areas are still sky-high. It’s not like there’s no demand for areas where you’re charging $300, $400 per square foot to rent these areas.

In the long term, all the economic push for both the landlords and the tenants is to get those units occupied and get the rent payments again flowing to the landlord.

Landlords, whether small or large, are often left out of public discussions about property markets. And if they’re not left out, they’re usually drawn as villains. Vicki Been, in thinking about the project she calls “Not Your Grandmother’s Rent Control,” is trying to change that.

BEEN: I think the thing that you really need to focus on is: how can I ensure that the landlord is getting a reasonable return, right? Because otherwise, people will take their money and put it elsewhere and you won’t get building. And how can we at the same time try to close some of these avenues that landlords could use to try to escape rent regulation without it becoming a system that’s so weighed down with so many different enforcement challenges that it kind of collapses of its own weight, right?

You need to pay attention to the different ways in which property owners are making money on the property, so you really need to have a holistic look. At the same time, you need to have very open-eyes view of the kinds of costs that we’re imposing on them.

There’s one huge cost that drives real-estate prices, whether we’re talking about rentals or sales, for both commercial and residential buildings.

BEEN: In New York City, for example, a very high percentage of rent goes for property taxes. So we can’t be saying to landlords, “Hey, keep prices down — but by the way, your property tax just went up by 10 percent. So we have to recognize that, okay, we as a taxpaying body have an obligation to understand the effect that those increases may have on rents, and we can’t just turn around and say to the landlord, “You absorb them,” right? “Don’t pass them onto the tenant.” Because that’s an unsustainable system.

GLAESER: It’s certainly true that renters implicitly have to pay for property taxes. And it’s not obvious that’s wrong, because the idea of property taxes is they’re paying for city services and renters use city services, too. That’s obviously not wrong.

DUBNER: So, here’s a big question that I really hope you can answer, because I’ve wondered this for a long time. Some of the biggest property owners in a city like New York — and some of the wealthiest property holders generally — are universities, religious institutions, hospitals, and other not-for-profit institutions, which makes them either partially or wholly exempt from paying property taxes. So, I’m curious, how does that exemption affect a) the taxes paid by everyone else, and how does that b) ultimately affect housing prices for everyone.

GLAESER: First of all: clearly, you’re right. The government has decided to subsidize certain institutions by enabling them not to pay property taxes. And from a purely accounting point of view, those taxes need to come from somewhere else.

On the other hand, it is also true that at least some of the institutions that you’re talking about have proven to be extraordinarily important for the economic health of the area, right? We’re subsidizing the university student, right? We’re making it cheaper for them to rent than it would be otherwise. Is that fair? Well, we thought that, somehow or other, it was a good idea to subsidize educational institutions at one point in time. We thought there might be some spillovers from that, some benefits from encouraging people to become educated. But, we should be open to re-investigating that, and anyway, you shouldn’t take my word for it, because after all, I’m the employee of an educational institution.

We can ask whether or not the blanket property-tax exemption that we’ve given to religious institutions and educational institutions is appropriate. I mean, that seems like a reasonable question to ask. In the case of religious institutions it in some sense goes back to fundamental issues about separation of church and state in the U.S., but we can still ask this question.

I would be surprised if we think that changing those tax rates is the number-one step to take to promote affordability in New York City though, relative to bringing more space on market that you can actually build on, changing the regulations. I mean, it seems like that’s not likely to be the case, but it is true that you move stuff to a religious or educational use, in many cases you’re moving away from an owner who would actually build on it. And that’s also correct.

So what have we learned about housing, especially affordable housing, especially in the most desirable cities? For starters, we’ve learned that it’s complicated. Property taxes play a large, underappreciated role in driving up costs, and the tax burden isn’t necessarily spread so equitably. Rent regulations, meanwhile, appeal to the public and politicians, but they also create perverse incentives that in the long run work against affordable housing. How about housing vouchers: aren’t they a more flexible way to subsidize housing?

BEEN: The advantage of a voucher is, you can go through all of those eligibility requirements and really target the voucher to the families that you think are most in need. And we in New York, and in many other major cities, we have prohibitions against a landlord refusing a tenant because they’re using a voucher rather than earned income.

But we’re still getting enormous resistance from landlords, because if you have a federal government that shuts down and isn’t paying its voucher payments, and there, the landlord is stuck with that, right? Or if you have a city, like New York City did, that issued vouchers and then changed its mind, and said, “Oops, that program is over,” then the landlord has a tenant in place who no longer can pay the rent and the landlord has to take them to court and bear the costs of that.

Meanwhile, the market price of housing in a place like Manhattan lies somewhere between punitive and prohibitive. So if rent control isn’t a viable tool in the fight for affordable housing, what is?

GLAESER: The most natural tool towards affordability is supply, and to make sure that we are making it easy enough to build moderate-cost rental-apartment buildings in these cities.

Ed Glaeser again.

GLAESER: We’ve used regulations to so restrict our ability to provide affordable housing units that now we’re at this restricted frozen-in-amber form. In the case of New York — gosh, New York is New York. It’s hard to imagine how much housing you’d really need to sate demand for New York.

DUBNER: What about Boston, where you live? Boston is facing what it calls a historic housing shortage. The city’s growing, not enough housing to match. What do you suggest Boston do to accommodate that surge, other than let the market work its famous magic?

GLAESER: Look, drive around Boston. It doesn’t look overcrowded to me, and I don’t think it should look overcrowded to anyone else. There’s a lot of vacant industrial space that could easily house tens of thousands of units. If you made it easy enough to build, I’ve got to think that this is a doable problem, at least from an engineering and economics point of view. The politics, of course, are more difficult.

DUBNER: What, specifically, would need to be done to change it?

GLAESER: So, the big answer is, you need, as-of-right zoning that enables fairly high-density levels over a fair amount of space. So, currently Boston’s zoning plan is highly antiquated. Every project is handled on an ad-hoc basis. Usually, it involves variances that are quite high from the original plan, which means that they are highly subject to judicial challenge. All of that is a recipe for uncertainty and delay and endless community meetings.

The thing that works best is when you have something where you’ve decided in advance, “This is how much we’re going to allow to build; there are a couple of simple rules that you’ve got to follow. Come here, bring your units and make it happen.” And that’s what’s needed. That’s what actually works. It’s not something that involves a 10-year negotiation process, but something that says, “Here are the rules upfront. Go to it.”

It should be noted that not all U.S. cities impose the same level of red tape you see in Boston and New York and San Francisco.

GLAESER: If you want to look for affordability, the American Sunbelt is pretty great. The Atlantas, the Houstons, the Dallases, the places that just have made it very easy to build over the last 40 years — you want to ask why Atlanta, Dallas, Houston, Phoenix each added a million people between 2000 and 2010 as metro areas, it’s because they make it astonishingly easy to build. And you can go and you can buy a great-looking house for a fraction of what you’d pay in New York in these places.

We don’t have an affordable housing crisis in the U.S. nationally. We have lots of affordable housing in places with names like Atlanta, but just not in New York City.

Many European cities, meanwhile, are more like New York — in fact, exaggerated versions of New York.

GLAESER: Much of Europe is quite restrictive in your cities, but I’m much more comfortable about the idea that much of central Paris is patrimony of the world that needs to be protected.

While policies vary from city to city and country to country, almost all major European cities have rent control.

GLAESER: Sweden, of course, is the place where Assar Lindbeck, the famous economist — and although he was market-oriented, he certainly skewed to the left — Assar famously said that, “short of bombing, I know of no way to destroy a city that was more effective than rent control,” and he certainly had Stockholm in mind.

Tommy ANDERSSON: Right now, there are around 10 million people living in Sweden. Around 550,000 of these people were standing in a queue waiting for an apartment in Stockholm. That is 5 percent of the Swedish population.

That’s the economist Tommy Andersson.

ANDERSSON: I am a professor at Lund University, which is located in the south of Sweden. I focus on an area called market design.

Sweden has nationwide rent control.

ANDERSSON: The rental system in Sweden is based on collective bargaining. So according to the Swedish law, there is a union called the Swedish Union of Tenants and their job is essentially to negotiate the rents for tenants. And it’s based on something which is called the utility value, which essentially means that if you have two comparable apartments, they should have the same rents. Another objective that they have is that they should keep the rents low. The rents cannot be increased by too much.

If you’ve been listening closely, it may not surprise you to learn that this system has led to a housing shortage.

ANDERSSON: Because people will not invest in new buildings unless they can get good returns. So if you look at this report written by the National Board of Housing, Building, and Planning from 2016, they estimated that Sweden needs around 440,000 new homes before 2020.

And that’s not going to happen. This shortage is what can lead to long lines to get an apartment, especially in the more desirable places. How long do you have to wait in Stockholm?

ANDERSSON: You have to wait for 10 or 20 or even 30 years to get an apartment right now, if you would sign up today.

What if you don’t want to wait 10 or 20 or 30 years for an apartment?

ANDERSSON: So, there are no official figures because it’s a black market. But it’s clear that there exists a black market. You can get an apartment in several different ways. So one of them is essentially to buy contract with black money. You can also bribe someone in charge of allocating available apartments to get the better position in the queue. And another thing which is popular is these fake swaps. So, you’re allowed by law to swap apartments with other persons. So you’re just pretending that you are swapping apartments, but essentially you’re not.

In the old days what I had heard — and I must stress that I don’t have any scientific evidence of this — but apparently, black contracts used to cost around 10 percent of the market value. But in recent years it has actually grown to say 20 percent of the market value of the apartment. So it’s expensive to buy a black contract. You know, it’s always a risk to be involved in this business because even if you paid the money, it’s not clear that you will get the apartment simply because, I mean, there are criminal gangs involved in this as well.

That doesn’t sound like what the designers of the Swedish rental system were going for. But the housing market in Stockholm is so bad that even business leaders there have risen up in protest.

ANDERSSON: The C.E.O. and the founder of Spotify, in 2016, he wrote an open letter to the people of Sweden saying that unless you solve this housing situation in Stockholm, Spotify may consider moving its headquarters out of Stockholm simply because we cannot find housing for our future employees.

If policy makers can’t figure out smarter ways to encourage more affordable housing, you can expect to see this kind of scenario playing out in cities all over the world.

* * *

Freakonomics Radio is produced by Stitcher and Dubner Productions. This episode was produced by Zack Lapinski. Our staff also includes Alison Craiglow, Greg Rippin, Harry Huggins, Matt Hickey and Corinne Wallace. Our theme song is “Mr. Fortune,” by the Hitchhikers; all the other music was composed by Luis Guerra. You can subscribe to Freakonomics Radio on Apple Podcasts, Stitcher, or wherever you get your podcasts.

Here’s where you can learn more about the people and ideas in this episode:

SOURCES

Rebecca Diamond, Associate Professor of Economics at Stanford Graduate School of Business.

David Eisenbach, history lecturer at Columbia University.

Vicki Been, former commissioner of the New York City Department of Housing Preservation and Development and law professor at the New York University School of Law.

Ed Glaeser, Fred and Eleanor Glimp Professor of Economics at Harvard University.

Tommy Andersson, economics professor at Lund University.

RESOURCES

“Roofs or Ceilings?: The Current Housing Problem,” by Milton Friedman and George J. Stigler (Foundation for Economic Education, Inc., 1946).

“An Econometric Analysis of Rent Control,” by Edgar O. Olsen (Journal of Political Economy, 1972).

“The Effects of Rent Control Expansion on Tenants, Landlords, and Inequality: Evidence from San Francisco,” by Rebecca Diamond, Tim McQuade, and Franklin Qian (National Bureau of Economic Research, 2019).

“Housing Market Spillovers: Evidence from the End of Rent Control in Cambridge, Massachusetts,” by David H. Autor, Christopher J. Palmer, and Parang A. Pathak (Journal of Political Economy, 2014).

The post Why Rent Control Doesn’t Work (Ep. 373) appeared first on Freakonomics.

from Dental Care Tips http://freakonomics.com/podcast/rent-control/

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elizabethcariasa · 6 years ago

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SALT deduction proposed regulations would make state tax charitable credit workarounds useless

One of the first questions I got when states started working on chartable programs that would let their taxpayers get around the new $10,000 cap on the deduction for state and local taxes (SALT) was how any Internal Revenue Service action might affect existing programs.

We finally have an answer and it's not good.

"Congress limited the deduction for state and local taxes that predominantly benefited high-income earners to help pay for major tax cuts for American families," said Secretary Steven T. Mnuchin in a statement accompanying the regulations. "The proposed rule will uphold that limitation by preventing attempts to convert tax payments into charitable contributions."

While the Treasury proposal targets the new SALT-specific programs, some similar state tax credit options that predated the Tax Cuts and Jobs Act (TCJA) could become collateral damage.

SALT limits: In order to offset the costs of the tax changes, particularly the new 21 percent rate for corporations, Congress eliminated or reduced some tax breaks.

The ability of individual taxpayers to claim state and local taxes on their federal returns was one of those changes. The tax break is still around, but only $10,000 per return (be it by a single filer or couples filing a joint 1040) can be claimed.

Granted, tax data shows that this change affects a small portion of the U.S. taxpaying population. But this elite groups tends to be in states that have for many years voted Democratic.

Many saw the limit as a twofer for Republicans in control of the House and Senate. They could recoup some money for their pet tax reform bill and simultaneously whack their political opponents.

But as is usually the case with taxes, things aren't that cut and dried. Residents in some areas of Republican leaning red states, particularly those with expensive homes that generate large previously fully deductible property tax bills, also will take a tax deduction hit.

So lawmakers in several states, notably New York and New Jersey, immediately began looking ways to work around the new deduction limit.

The general approach is to establish a state-run charity that could accept donations from taxpayers to pay for state programs. These donations would be the amounts they previously paid as state and local taxes, which are now limited.

But since the TCJA did not limit the amount of charitable contributions an itemizing taxpayer can claim, they would get to deduct the full amount of their new charitable gift.

Not so fast: As you can imagine, the Treasury Department and IRS were not impressed. They indicated their skepticism in a notice issued in May, noting:

"Despite these state efforts to circumvent the new statutory limitation on state and local tax deductions, taxpayers should be mindful that federal law controls the proper characterization of payments for federal income tax purposes."

Today, Uncle Sam's top money men made that sentiment official.

Treasury Regulation 112176-18 says that basic charitable donation rules that determine the size of a tax deduction when something is received in connection with that gift apply to the SALT workarounds.

That means, according to the proposed rule, if a taxpayer receives a state or local tax credit for making a charitable contribution, then the amount that taxpayer can claim on his or her federal tax return as a deductible donation must be reduced by the amount of that benefit.

That, said Mnuchin, is straightforward application of a longstanding principle of tax law: When a taxpayer receives a valuable benefit in return for a donation to charity, the taxpayer can deduct only the net value of the donation as a charitable contribution.

No break for donation-related gifts: It's basically the often-cited PBS tote bag rule. You give your local public television station $100 and get a $10 tote bag as a thank-you gift. You can only claim $90 on your federal taxes.

In the case of taxes, you give $20,000 — the amount you paid in state and local income and property taxes — to your state's new charity. In return, you get an 80 percent state tax credit for your gift.

Instead of deducting your $20,000 you now must subtract the credit you got in return, or $16,000 in the example above.

That means you can claim only $4,000 as a charitable deduction.

In this case, you'd be better off just paying your state and local taxes as usual and claiming the $10,000 now allowed.

Of course, if you're really rich and your SALT amounts are much larger, say $100,000 instead, you'd get a $20,000 charitable deduction, which is double the 10K cap.

Exemption, refusal and more: For smaller amounts, the proposed regs say that if a state tax credit is less than 15 percent, then the taxpayer would get the full charitable deduction.

The regulations note that this de minimis exception reflects that the combined value of a state and local tax deduction; that is, the combined top marginal state and local tax rate, currently does not exceed 15 percent.

And as in the case of other charitable donations, Treasury is proposing that giver have the option to refuse the gift, or in this case, the tax credit.

In such cases, the full charitable contribution deduction would be allowed if the taxpayer does not accept or keep any tax return benefit.

Because procedures for declining the state or local tax credit would depend on the procedures of each state and locality in administering the tax credits, Treasury wants to hear from them and taxpayers on this idea.

Also note that these regs would apply only to instances where a taxpayer receives a state tax credit. Nothing would change where taxpayers get a state tax deduction for charitable gifts.

Potential problems for existing state credits: I suspect that the states who have proposed or are working on ways to help their taxpayers retain their SALT deductions are not going to be thrilled with these regs.

And folks in other states that have existing state tax credit programs are going to be just as, if not more, unhappy.

The new regs don't differentiate between state credit programs already in place (many of them for years) and the new state charity credits to circumvent the SALT deduction cap.

A/ paper authored by a group of tax law professors and academic associates cites more than 100 such programs in 33 states. They range from gifts that cover conservation easements to funding for hospitals to private school tuition scholarship programs.

Although the popularity of these state tax credit programs has grown dramatically in recent years, they've managed to stay under IRS radar.

Mnuchin said that the proposed rule shouldn't affect most of these programs. Only about 1 percent of taxpayers are expected to see an effect on tax benefits for donations to school choice tax credit programs.

"We appreciate the value of state tax credit programs, particularly school choice initiatives, and we believe the proposed rule will have no impact on federal tax benefits for donations to school choice programs for about 99 percent of taxpayers compared to prior law," said the Treasury Secretary.

The reason, noted Mnuchin, is the increase in the standard deduction under the new tax law. Treasury projects that 90 percent of taxpayers now will claim the standard deduction instead of itemizing, rendering the charitable deductions they previously claimed moot.

But the added IRS attention to such programs has some states worried.

Sure, some participants likely will continue if they get a state-level tax break. But other donors might opt out, reasoning that they don't want the IRS taking an extra look at their filings for such a deduction.

And some prior donors might not be so inclined to give now since they, as Mnuchin notes, aren't itemizing any longer. That makes every charitable donation, be it through a state tax credit program or the traditional giving method, worthless from a federal tax standpoint.

Time frames: Treasury is aware that some folks have already taken or plan to take tax action in connection with state charitable credit programs.

That's why it says the proposed regulations would apply only to contributions made after Aug. 27, protecting those who donated earlier this year or who give in the next few days.

Also, note that these regulations are proposed. Treasury has scheduled a hearing on the regs for Nov. 5. It will start at 10 a.m. Eastern Time in the Auditorium of the IRS building at 1111 Constitution Avenue, N.W. in Washington, D.C.

You have until Oct. 11, the official 45 days after the official publication of the regs in the Federal Register, to get your comments on the proposal to Mnuchin and company by snail mailing them to:

Internal Revenue Service CC:PA:LPD:PR (REG-112176-18) Room 5203 P.O. Box 7604 Ben Franklin Station Washington, D.C. 20044

If you prefer, you can hand deliver submissions, Monday through Friday between the hours of 8 a.m. and 4 p.m. Eastern Time, to the IRS building. Address the package to:

CC:PA:LPD:PR (REG-112176-18) Courier's Desk 1111 Constitution Avenue, N.W. Washington, D.C. 20224

Treasury also will accept electronic comments via the Federal eRulemaking Portal at www.regulations.gov. Note IRS and REG-112176-18 on your e-comments.

You also might find these items of interest:

Tax reform's $10K property tax deduction is worthless

4 states seek court help in ending limit on SALT deduction

Property tax appeals likely in wake of new federal deduction limit on state and local taxes

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stephenmccull · 5 years ago

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COVID-19 Crisis Threatens Beleaguered Assisted Living Industry

David Aguirre jumped in his truck and drove toward the hospital in the predawn darkness the minute he got the news: His 91-year-old mom was being rushed from her Texas assisted living facility to the emergency room.

Estela Aguirre would be one of five residents to die and six others to be sickened by the novel coronavirus at The Waterford at College Station, part of a financially strapped chain of assisted living sites called Capital Senior Living.

“My mom was a sweet, kind person. People really felt like they’d known her for 100 years. She was just that kind of soul,” said Aguirre, who lost his mother on March 28. “Some days, I’ll sit down and have my heart cry.”

Assisted living complexes, home to more than 800,000 people nationwide, have quickly become a new and dangerous theater in the coronavirus war. Challenged by deepening financial pressures, sicker residents, limited oversight and too few employees, they now face a crisis that could force companies into bankruptcy, roil the industry and even close some facilities — putting frail seniors at greater-than-ever risk.

More than 700 cases of COVID-19 at assisted living facilities had been reported in at least 29 states as of Wednesday, according to public health authorities and news organizations.

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Capital Senior Living serves as a prime case study of the new dangers facing the assisted living industry and the people they serve. The Dallas-based company, which owns or operates more than 120 senior communities nationally, told investors on a March 31 conference call that residents at three of its facilities had tested positive for the coronavirus.

Even before those cases struck, though, the company was ailing. Its stock had plummeted 80% since late February. Last week, the company disclosed a 2019 loss of $36 million. Officials said on the conference call they had sold complexes in recent months, even before the surge of COVID-19 cases, to improve the firm’s financial cushion. Recently renegotiated leases will also help, they said.

The pandemic looks poised to exacerbate its finances further, as residents lose their ability to pay amid the faltering economy and costs rise to care for them.

And fragile economics compound the threat of the virus that rages through assisted living facilities, which are much less regulated and medically equipped than nursing homes but serve tens of thousands of America’s most vulnerable elders.

Estela Aguirre died on March 28 after being sickened by the novel coronavirus at an assisted living facility in College Station, Texas.(Courtesy of David Aguirre)

Problems Magnified

When Georgia officials inspected Capital Senior Living’s Waterford at Oakwood facility in February, their report said it “failed to provide watchful oversight consistent with the residents’ needs.”

Employees and residents told inspectors more staff was needed, and a review of the call log showed it sometimes took more than half an hour for workers to respond to residents, according to the inspection report.

Company officials said in a written statement that they can’t comment on individual cases but that “our top priority is always the safety of our residents and employees.”

The company lists at least 650 job openings on its website, many for credentialed positions such as certified nursing assistant or certified medical assistant. But a Facebook post on an Iowa facility’s website says: “If you are interested in a nursing aid position, you do NOT have to be a CNA and will be trained on site.”

With 6,300 employees, the company said, it “always has several hundred job openings.” As employees are furloughed in other industries, it said, it “has accelerated its activities to seek top talent.”

Staffing levels have grown in importance — and become harder to adequately address — in assisted living facilities as people increasingly “age in place” and try to avoid expensive nursing homes.

“In many ways, today’s assisted living residents are yesterday’s nursing home residents,” said Robyn Grant, director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care. “You have a perfect storm, with the needs increasing while [regulatory] requirements have not kept up with that.”

Grant said virtually no federal standards for assisted living exist, as they do for nursing homes. “We have a patchwork of regulation. In some states, you have more robust protections. In some, they are weak and inadequate. For residents, it is the luck of geography.”

As the pandemic grows, advocates for seniors worry that conditions will worsen as employees stop coming to work because they fear COVID-19 or must stay with children whose schools have closed. Or they may contract the coronavirus themselves.

“We’re really concerned about this when residents need more staff than ever,” said Tony Chicotel, an attorney with California Advocates for Nursing Home Reform. “We’re gonna have the opposite.”

There are more than 25,000 assisted living facilities across the country, and the median monthly cost to live in one is $4,000, according to the National Center for Assisted Living. Residents, more than half 85 or older and often with arthritis, memory problems and depression, need help with daily tasks but receive less medical attention than in a nursing home. That’s because assisted living staffs are typically smaller and the workers have less health care training than those at nursing homes. And fewer than half the states have minimum staffing regulations for assisted living communities.

Sheryl Zimmerman, a professor in the School of Social Work at the University of North Carolina at Chapel Hill, said only about half have a nurse on staff, and many workers are personal care aides, not certified nursing assistants. Staffers don’t receive as much training about things like the use of gloves and masks as do nursing home workers, even though they often help residents with eating, bathing or using the toilet.

“It’s not a health care workforce,” she said. “In general, they do not have the level of infection prevention you would hope to see.”

Staff shortages exacerbate this issue, and the surging economy and low unemployment before the pandemic meant many senior communities were already struggling to hire employees, said Amy Orlando, a Connecticut attorney specializing in elder law.

Rising wages to attract or retain workers and fierce competition fueled by a building boom a few years ago led to financial challenges at many assisted living facilities, said Beth Burnham Mace, chief economist for the National Investment Center for Seniors Housing & Care, a nonprofit research organization.

Financial Straits

Capital Senior Living is among the companies under extreme pressure.

As the company’s stock price has fallen to a few dimes, investors fear a possible bankruptcy filing, financial analysts said in interviews. They are worried new residents will stop moving in as others leave or die, hurting revenue. More than half its communities are below 90% occupancy, according to an executive on the conference call. Analysts say that level is roughly the minimum needed for profitability.

“I have confidence in our ability to continue delivering great service and a warm, caring environment to our residents,” Brandon Ribar, the company’s chief operating officer, told stock analysts on the call.

The company declined to make executives available to KHN for an interview but said it is “exercising extreme caution” and “following strict disinfecting and sanitizing guidelines.” Among the safeguards are screening anybody entering a facility and quarantining new residents for their first 14 days.

But one analyst raised a dire scenario if the pandemic worsens: the theoretical closure of facilities.

“Is there a certain rule of thumb, where if occupancy hits a certain point you just say, ‘Hey, let’s just shut down this facility, because we’re just going to lose too much money?’” Steven Valiquette, of Barclays Capital, asked executives on the conference call.

CEO Kimberly Lody, who was brought into the company last year, dismissed the concern, saying Capital Senior Living has “strong flexibility” to reduce staff and other costs if the number of residents decreases substantially at particular facilities.

Assessing The Quality Of Care

Several relatives of the facilities’ residents said they put their trust in staff members because they’ve generally been happy with their loved ones’ care.

Barry Curtis, whose 85-year-old mother, Orvaline, lives at the company’s Sugar Grove facility in Plainfield, Indiana, said he knows staffing can be a problem for communities but hasn’t seen much turnover at Sugar Grove or heard complaints about staffing from his mom. But the pandemic has revived old, haunting memories of her father telling her about pulling carts down Arkansas streets to pick up bodies during the 1918 flu.

Debbie Gilbert, whose brother Donald Bussey lives in assisted living at River Crossing in Charlestown, Indiana, said staffing has also been “pretty consistent” at the site. “They’re doing the best they can out there,” she said.

Assessing the quality of care is difficult. There’s no assisted living resource comparable to Nursing Home Compare, a federal website that includes star ratings, staffing levels and inspection results for nursing homes.

A KHN review of online inspection records in nine of the 23 states in which Capital Senior Living operates found dozens of problems in the past five years, including instances of insufficient staff, inadequate infection control and failure to screen employees for criminal violations. However, it is difficult to compare the overall quality of the company’s facilities to those of other companies within most states or around the country.

But within California, records show the company’s Garden Court at Villa Santa Barbara had 16 substantiated allegations since mid-2016, more than four times the average number among licensed facilities with at least one.

For example, inspectors last year found the facility contracted with an outside agency that could show no proof it was certified to provide home services to residents. Inspectors also found that staff members contracted to provide care had no records of training or licensing as skilled professionals such as registered nurses or licensed vocational nurses. The facility pledged to ensure staffers have basic training and that outside agencies have credentials before starting work.

The company added it has a “rigorous Quality Assurance program” and has instituted new leadership across the company that has “positively impacted operations and resident care.”

COVID-19 threatens to erode oversight and transparency even more. Long-term care ombudsmen, who traditionally went to facilities and talked to residents, now must assess care from afar because of restrictions on visitation. And COVID-19 has removed another type of helping hands and watchful eyes.

“We know when family and friends are visiting, they’re monitoring, seeing the condition of their loved ones,” Grant said. “They are now without those additional ears and those additional eyes.”

And there’s always a foreboding, a sense the virus could find its way into the facility — as it did in Texas.

“My mom was a sweet, kind person,” says David Aguirre (standing, right) of his mother, Estela Aguirre, pictured with her family. “People really felt like they’d known her for 100 years. She was just that kind of soul.”(Courtesy of David Aguirre)

Aguirre said his mom was in relatively good health for her age. She had memory problems, congestive heart failure and Parkinson’s disease, but her symptoms were mild.

Aguirre said his family was pleased with the care she got at the Waterford. The Brazos County Health Department said the facility had taken steps to prevent the spread of COVID-19 by restricting visitors, screening staff and using “enhanced cleaning procedures.”

“I still hold very high praise for the staff in the facility,” Aguirre said. “They’re doing all they can with everything they’ve got.”

By the time a hospital doctor broke the news to Aguirre of his mother’s positive COVID-19 test, there was no way to save her because her lungs were so badly damaged.

The doctor offered him the chance to say goodbye if he wore protective equipment.

But Aguirre, 67, said he feared being sickened by the virus or spreading it to his family.

So he missed seeing her draw her last breath.

COVID-19 Crisis Threatens Beleaguered Assisted Living Industry published first on https://smartdrinkingweb.weebly.com/

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