Nurses, Long Term Care, Miami, and Laws
We have talked before about travel nurses, and how the pandemic exposed critical shortages in the American health care system. Travel nursing is the perfect encapsulation of this country’s just-in-time, on demand economy - paying premiums to fly in critical staff for a week or a month to fill gaps at hospitals, because hospital budgets focus on cost-cutting rather than being prepared for a surge in demand.
As the pandemic dismantled America’s tenuous infrastructure, it forced a lot of nurses and hospital administrators to confront the uncomfortable fact that nursing is a tough job, often with lousy pay and grueling hours. And suddenly, faced with the opportunity to make more money for less work, a bunch of nurses said yeah, that sounds good to me:
In 2020 alone, Northwest [Texas Healthcare System hospital] lost 185 nurses — nearly 20 percent of its nursing staff. In the I.C.U., that number was closer to 80 percent. Many of those nurses left to take jobs with travel-nursing agencies, which placed them, on a temporary and highly lucrative basis, in hospitals throughout the country.
Hospitals lost staff to travel nursing, and then had to hire travelers to fill the gaps. It was predictable, given the state of the nursing profession:
Bedside nursing has always been, as one hospital chief executive put it, a “burnout profession.” The work is hard. It is physical and emotional. And hospitals have built shortages into their business model, keeping their staffs lean and their labor costs down.
In a survey of critical-care nurses last year, 66 percent of respondents said they were considering retirement.
The average salary of a staff nurse in Texas is $75,000. They work 12-hour shifts under emotionally and physically grueling conditions, often dealing with difficult patients and families. They witness illness, death, and grief. Often, because hospitals work on thin margins, they’re expected to handle more patients than they can safely cover, breeding anxiety and guilt if they aren’t able to provide adequate care.
During the pandemic, the federal government and states stepped in to give hospitals the funds to help afford travel nursing:
In July 2020, Texas established a statewide emergency staffing system, coordinated by select regional advisory councils. The state has put $7 billion in relief funds toward supplementing staffing, which has allowed hospitals like Northwest to attract travel nurses without shouldering the full cost. “The problem is that their salaries were so much higher than our employee salaries,” said Brian Weis, the chief medical officer at Northwest. “Our employed nurses were doing the same job, but they’re saying, ‘Why are we getting paid a fraction of what these nurses are?’”
Yes, if I were a staff nurse working alongside a travel nurse making three or five times my salary, I’d be asking the same question! Adding to the hospital industry’s woes are the many new opportunities for nurses to take less stressful jobs working normal business hours:
There are also more job opportunities beyond the bedside than ever. Nurse practitioners treat patients in doctors’ offices; insurance companies employ thousands of nurses; Microsoft and Amazon have hundreds of open nursing jobs. Today, only 54 percent of the country’s registered nurses work in hospitals.
This predicament is a result of decades of hospital privatization, decreased public health funding, and the perverse incentives created by our for-profit, privatized health insurance industry. Like teaching, nursing is more of a calling than a job you choose to get rich. It’s challenging in the best of times, but comes with the reward of helping people and solving difficult problems. During COVID-19, however, it’s become a more dangerous job, made worse by the anger and abuse hurled at nursing staff by families of the sick and dying:
Families of patients now yell at staff daily, asking for unproven treatments or accusing nurses of doing harm. They oppose intubation or refuse to wear masks. [Nora] Shadix still remembers the time a family blamed her for the death of their loved one. “I will always have compassion for my patients,” she said. “But I’m running out of compassion for the families.”
Conservative estimates predict the US will have a shortage of over 194,000 RNs each year for the next ten years. If the pandemic stretches out for years - as each wave seems to indicate is a likely scenario - and government support for hospitals ends, the country is going to have to reckon with what happens when hospitals close, emergency care is rationed, and there simply aren’t enough people willing to care for our sick and dying.
Long Term Care
Santa Rita is among hundreds of long-term care facilities nationwide -- from large chains to mom-and-pop operations -- that are fighting for their survival. Many are being forced to close their doors, while others are having to turn patients away in order to survive.
According to the American Health Care Association and National Center for Assisted Living (AHCA/NCAL), which represents more than 14,000 long-term care facilities, more than 75% of operators had to limit admissions in 2021. And more than 300 nursing homes have closed since the pandemic began.
Like hospitals, long term care facilities losing employees to burnout or illness have had to turn to high-priced staffing firms for help. The federal government has been providing aid to the industry for the last two years to help defray the increased costs, but that is coming to an end in two months:
Officials say hundreds more facilities are expected to close this year -- and if the federal government's COVID-19 emergency funding expires in July, advocates say, the situation will only get worse.
AHCA/NCAL calls the current staffing shortages "historic." The long-term care industry overall was already expected to face shortages of millions of workers before the pandemic, according to PHI National, a nonprofit research organization. And according to the Service Employees International Union (SEIU), over 400,000 workers -- nearly 10% of the workforce -- left the long-term care industry between March 2020 and January 2022.
Again, these are difficult, thankless jobs. Working with injured or chronically ill patients for long shifts is challenging in the best of times. Having competent staff on site is critical for the facilities, and while staff accounts for around 70% of their expenses, those staff are making near poverty wages:
And yet, the median pay for certified nursing assistants in 2020 was $14.82 an hour, according to the Bureau of Labor Statistics.
Understandably, when faced with the choice of working at a rehab facility or making more working at Walmart many long term care workers are dropping out of the market.
How bad could the problem get? If the emergency Medicare assistance to facilities ends in July - as it likely will, with Congress refusing to pass additional pandemic aid - more than four hundred thousand patients could be without beds:
That could leave up to 417,000 patients and families scrambling to find the care they need.
"The financial pressures are just too much," Malkin, in Arizona, said. "Places are going to close ... places are definitely going to close."
In a country where health insurers are making record profits during a pandemic while nurses, doctors, and other critical health workers are quitting in droves and the populace gets sicker it’s another grim reminder of how little our health system actually cares about quality of life for anyone unlucky enough to get caught up in it.
Miami is a city - actually three cities, more on that later - that has been trying hard to keep itself in the news. They built an F1 track - and a fake marina - in a stadium parking lot. One (of the three!) mayors has embraced crypto, which is going well:
On Feb. 2, the city of Miami cashed out its cryptocurrency MiamiCoin for the first time, depositing $5.25 million into city coffers. Miami mayor Francis Suarez hailed it as a “historic moment” and predicted the cryptocurrency could one day even replace municipal taxes as the government’s primary source of funding.
Over the last nine months, however, MiamiCoin has lost nearly all of its value, falling about 95% from its September peak to just $0.0032 as of May 13. Its rapid descent has burned investors on the way down, muting the dreams of Miami’s city leaders, and possibly raising red flags for regulators now investigating cryptocurrency transactions.
Ah well, who could have predicted:
MiamiCoin is the first in what CityCoins, a Delaware-based company with a mailing address in a Los Angeles strip mall, has promised will be a series of US city-branded cryptocurrencies.
Anyhow, Miami has been a recent darling in the tech press because during the pandemic, loose regulations - and no state income tax - led to a modest bump in immigration:
In 2020, Miami attracted 15% more tech workers in 2020 compared to before the pandemic, while a record $4.6 billion in new venture capital investment poured into its tech sector in 2021.
It’s also led to skyrocketing rents, but that’s a problem for people who don’t have tech salaries. But what is Miami, as a city? What is its identity? Is it going to turn into a libertarian crypto paradise? Is it going to become the next San Francisco or Austin? Or is it simply a loosely-regulated, shoddily built mess of excess that’s increasingly vulnerable to extreme weather and disaster?
Whenever I think of Miami now, I think of this excellent piece by Joel Stein for the Financial Times:
But now Miami is the most important city in America. Not because Miami stopped being a frivolous, regulation-free, climate-doomed tax haven dominated by hot microcelebrities. It became the most important city in America because the country became a frivolous, regulation-free, climate-doomed tax haven dominated by hot microcelebrities.
And boy, Miami is all of those things and more. Stein talks to Miami locals who seem baffled anyone is moving to the city for non-criminal reasons. Real estate in the city continues to sell for eye-popping sums, despite the fact the city is going to be underwater by the time their great-grandchildren are old enough to inherit:
A 2018 report from the Union of Concerned Scientists estimated that 94 per cent of Miami Beach would be underwater by 2100. Already, because Miami sits on porous limestone, the ocean regularly seeps up on to the streets.
People are flocking to Miami - they’ve even got a “Billionaire Bunker” - to pay insane sums for houses that may not last more than a couple decades without massive infrastructure investment from the city which, given its track record, seems like a long shot.
Francis Suarez has become the face of Miami, the charismatic crypto mayor who encourages VCs and hedge funds to move to the city. But, like many things Miami, much of his persona is a facade:
Compared with other cities, Miami’s mayorship doesn’t come with much power. The mayor of Miami-Dade has more control of the area, and Miami Beach has its own mayor. The mayor doesn’t get a vote on the city council, and Suarez’s 2018 ballot initiative to secure more mayoral power failed. When I arrived at City Hall, I feared I had the wrong address. It’s a small, two-storey building on the marina, away from downtown, and the mayor’s staff of 15 use only the second floor.
His job is part-time, and during the day he’s a trial lawyer. He works with Miami’s other two mayors to grow the city’s business base and - perhaps a few decades too late - to combat the effects of climate change on the city. Maybe their efforts are in earnest, and maybe with significant investment Miami can slow down the rest of the world’s attempts to cook the planet and general disregard for what two feet of sea level rise would mean for coastal centers. But I’ll let local activist Billy Corben weigh in on what he thinks is going on:
“Don’t come here and tell me how competent and excellent the government is and how easy it is to commute and how great the customer service is,” he says. “Three of the deadliest structural collapses in the last 10 years occurred in one county. That’s not even including the other structural failures that were not deadly. One county, dude. This is a third-world government and a fourth-world infrastructure, at the risk of insulting the fourth world.”
He notes that the school board banned an elementary school book about culture for not being harsh enough about Cuba’s government. “It’s not freedom, here. It’s economic freedom.” Corben believes Miami’s importance will fade with the virus. “A disposable city suddenly feels essential. It’s a mistress. People lived in places that mattered, and they came into contact with the fragile nature of life and needed a moment. If Miami were to disappear off the map tomorrow it would be of no consequence. No industry would disappear. It’s not a movement,” he says. “A Miami Movement is what happens after I eat at Sergio’s.”
In the present moment, Miami feels vibrant, colorful, and - for people who feel inconvenienced by the pandemic - free of responsibility or obligation. Unfortunately, that same attitude went into building Miami, and the long term reality is likely as fragile and unstable as its finances and architecture.
Yesterday, the 5th Circuit did this:
John P. Collins @prof_jpcThis seems like a pretty consequential decision https://t.co/DiyNjlygtt https://t.co/ghlsYyvdl8
According to this analysis in the NY Times, the court objected to the SEC’s use of administrative law judges - in-house judges the agency uses to decide some enforcement actions. Matt Levine explains why letting regulatory agencies make and enforce rules - with power granted originally by Congress - can be a good thing:
There are obviously good reasons to do things this way. Congress does not have time to write all the rules, so delegating rulemaking to agencies is efficient. Congress also has limited subject-matter expertise: The SEC knows more about securities law and financial markets than the average congressperson, so it makes sense for the SEC to write most of the securities rules. The rulemaking process is often both more flexible and more thoughtful than the legislative process; agencies have to consider public comments and explain their reasoning in a way that Congress does not.
It can also be a bad thing, as we learned last week. For a long time, the SEC and other governmental agencies were able to make and enforce rules with pretty wide discretion under the law - here is the lawerly explanation of how and why:
The Supreme Court has adopted an “intelligible principle” test, saying that if Congress delegates authority to an agency and gives it an “intelligible principle” to follow, then the agency can constitutionally make rules guided by that principle. This is a vague test and in practice, for the last 87 years, it has always been met. For instance, Congress has given the SEC pretty broad authority to make disclosure rules that are “necessary or appropriate in the public interest for the protection of investors,” which gives the SEC a lot of discretion but which is probably “intelligible” enough under current law.
But! Now that lots of Republican judges want to limit what regulatory agencies can do, the “nondelegation doctrine” is an issue:
But the third reason is the nondelegation doctrine: The Fifth Circuit found that Congress unconstitutionally delegated to the SEC the power to decide whether to bring cases in federal court or before its own ALJs.
This strikes me as a little weird — surely deciding what forum to sue in is an executive action, not a legislative one? — and not at all necessary to the decision.
What the court is doing is teeing up the Supreme Court - Gorsuch in particular - with an argument that Congress giving agencies like the SEC authority to write rules and decide where to charge cases is unconstitutional. It’s an important reminder that just because things have been done a certain way for eighty years - or fifty - doesn’t mean a small number of ideologue judges can’t walk in the door and change the rules.
The same 5th Circuit now appears to be poised to rule against how the CFPB is funded:
When it created the CFPB in 2010, a Democratic-controlled Congress tried to insulate the agency from political pressure by putting it within the Federal Reserve System and mandating a single director who could only be fired for cause.
The Fifth Circuit has signaled it may be the first appeals court to rule against the agency’s funding mechanism in Community Financial Services Association of America Ltd. v. CFPB, a case over the agency’s payday lending rule.
A conservative federal circuit court appears to be trying to systematically dismantle a bunch of regulatory enforcement powers that happen to impact finance and industry - the EPA, CFPB, SEC, and FTC have long annoyed conservatives and the business community because they serve as a thin barrier against the lawless pursuit of profit. This has been the right wing judicial project for decades now, and it may be reaching its zenith. The problem with stripping one or two agencies of their power is - where does it end? We talk a lot about the various industry groups trying to shed what they view as excessive governmental regulation. What if they all got what they wanted?
Chicago Tribune - “The nearly 30 students summoned to the Tazewell County Courthouse that January morning were not facing criminal charges; they’d received tickets for violating a municipal ordinance while at school. Each was presented with a choice: agree to pay a fine or challenge the ticket at a later hearing.”
WSJ - “The 2022 pace of roughly a hack a week is in line with last year, but the amount stolen is rising, according to Rekt. Since August, there have been 37 hacks in 38 weeks that have drained about $2.9 billion worth of cryptocurrencies.”
NBC News - “Costa Rica has declared a state of emergency after ransomware hackers crippled computer networks across multiple government agencies, including the Finance Ministry.”
NBC News - “Lincoln College is scheduled to close its doors Friday, becoming the first U.S. institution of higher learning to shut down in part due to a ransomware attack.”
Tips, thoughts, or money for more nurses to firstname.lastname@example.org