NEJM Interview: Mark Unruh on projected increases in the need for long-term services and supports in the United States amid declines in nursing-home capacity.

The United States is facing long-anticipated growth in the population of people eighty years of age or older. Meanwhile, in recent years, there's been an unexpected contraction in nursing home supply. I'm Stephen Morrissey, Managing Editor of the New England Journal of Medicine, and I'm talking with Mark Unruh, an Associate Professor of Population Health Sciences at Weill Cornell Medical College. Dr. Unruh has co-authored a perspective article about the simultaneous pressures of an aging population and decreasing nursing home supply. Dr. Unruh, roughly how many older adults are expected to need long-term services and supports in coming years?

I don't have a specific number for the projected number of people who will need long-term care moving forward. However, currently, there are about one point two four million individuals in the United States receiving care in nursing homes. Now, the population age eighty and older is expected to grow by about forty-five percent over the next decade. This is an age that's associated with elevated risk of disability, dementia, as well as need for, uh, assistance with activities of daily living. So even if current nursing home supply holds steady, it's not expected to be sufficient.

And then, as you say in your perspective article, many of the nursing homes that might have cared for those people have closed in the past ten to twenty years. So how much capacity does the U.S. nursing home system have to care for new residents now?

So it's estimated that the average occupancy rate of nursing homes is about eighty-four percent in the United States. However, that doesn't account for the number of beds that are actually online. So if you count the number of certified beds, that may underestimate the availability of, of nursing home care.

What contributed to the high closure rates in recent years? Why are nursing homes closing?

Nursing homes most at risk of closure tend to have a high percentage of stays covered by Medicaid. These are individuals receiving long-term care. As you may know, nursing homes care for two populations, those receiving post-acute care, typically following a hospital discharge, and also individuals receiving long-term care. Now, a common misconception is that Medicare covers long-term care, which isn't the case. Medicaid, if your income and assets are low enough, does cover long-term care, and about two-thirds of individuals receiving long-term care in nursing homes have those stays covered by Medicaid. And nursing homes with a disproportionate share of Medicaid-covered stays are at higher risk of closing.

Both you in your article and Olinsky and Grabowski in another perspective article talk about workforce constraints in this sector. Why haven't nursing homes been able to recruit and retain sufficient staff?

Staffing is a, a key issue in terms of nursing homes' operating capacity. So there's been a decline since the pandemic in the level of staffing in nursing homes. They've had, as you point out, a difficult time recruiting and retaining staff, and there are some reasons that were present even before the pandemic, which COVID-19 amplified, behind declining levels of staffing. For example, these