A Biden administration rule that imposed minimum rules on nursing levels may not survive, even though many homes lack enough workers to maintain residents’ care.Covid’s rampage through the country’s nursing homes killed more than 172,000 residents and spurred the biggest industry reform in decades: a mandate that homes employ a minimum number of nurses.But with President-elect Donald Trump’s return to the White House, the industry is ramping up pressure to kill that requirement before it takes effect, leaving thousands of residents in homes too short-staffed to provide proper care.The nursing home industry has been marshaling opposition for months among congressional Republicans — and even some Democrats — to overrule the Biden administration’s mandate. Two industry groups, the American Health Care Association and LeadingAge, have sued to overturn the regulation, and 20 Republican state attorneys general have filed their own challenge.Consumer advocates, industry officials and independent researchers agree that the incoming administration is likely to rescind the rule, given the first Trump administration’s “patients over paperwork” campaign to remove “unnecessary, obsolete, or excessively burdensome health regulations on hospitals and other healthcare providers.” Among other things, Mr. Trump aided the industry by easing fines against homes that had been cited for poor care.“The Trump administration has proven itself really eager to reverse overreaching regulations,” said Linda Couch, the senior vice president for policy and advocacy at LeadingAge, which represents nonprofit elder care providers. “We think it’s got a pretty good chance of being repealed, and hope so.”Issued in April, the staffing regulation requires nursing homes to have registered nurses on site around the clock — something that the industry has endorsed — and to maintain minimum numbers of nurses and aides. Four of five homes would have to increase staffing. The requirements would be phased in, starting in May 2026.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

For hours, John A. Pernorio repeatedly mashed the call button at his bedside in the Heritage Hills nursing home in Rhode Island. A retired truck driver, he had injured his spine in a fall on the job decades earlier and could no longer walk. The antibiotics he was taking made him need to go to the bathroom frequently. But he could only get there if someone helped him into his wheelchair.By the time an aide finally responded, he’d been lying in soiled briefs for hours, he said. It happened time and again.“It was degrading,” said Mr. Pernorio, 79. “I spent 21 hours a day in bed.”Payroll records show that during his stay at Heritage Hills, daily aide staffing levels were 25 percent below the minimums under state law. The nursing home said it provided high-quality care to all residents. Regardless, it wasn’t in trouble with the state, because Rhode Island does not enforce its staffing rule.An acute shortage of nurses and aides in the nation’s nearly 15,000 nursing homes is at the root of many of the most disturbing shortfalls in care for the 1.2 million Americans who live in them, including many of the nation’s frailest old people.They get festering bedsores because they aren’t turned. They lie in feces because no one comes to attend to them. They have devastating falls because no one helps them get around. They are subjected to chemical and physical restraints to sedate and pacify them.California, Florida, Massachusetts, New York and Rhode Island have sought to improve nursing home quality by mandating the highest minimum hours of care per resident among states. But an examination of records in those states revealed that putting a law on the books was no guarantee of better staffing. Instead, many nursing homes operated with fewer workers than required, often with the permission of regulators or with no consequences at all.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

Here are the telltale signs to look for in nursing homes to avoid, and resources that can point to better places.Few people want to go into a nursing home, but doing so can be the right choice if you or a loved one is physically or cognitively disabled or recovering from surgery. Unfortunately, homes vary greatly in quality, and many don’t have enough nurses and aides to give residents the care they need.How do I find nursing homes worth considering?Start with Medicare’s online comparison tool, which you can search by city, state, ZIP code or home name. Ask for advice from people designated by your state to help older and disabled people searching for a nursing home. Every state has a “no wrong door” contact for such inquiries.You can also reach out to your local area agency on aging, a public or nonprofit resource, and your local long-term care ombudsman, who helps residents resolve problems with their nursing home.You can find your area agency on aging and ombudsman through the federal government’s Eldercare Locator website or by calling 1-800-677-1116. Identify your ombudsman through the National Consumer Voice for Quality Long-Term Care, an advocacy group. Some people use private placement agencies, but they may refer you only to homes that pay them a referral fee.What should I find out before visiting a home?Search online for news coverage and for reviews posted by residents or their families.Call the home to make sure beds are available. Well-regarded homes can have long waiting lists.Figure out how you will pay for your stay. Most nursing home residents rely primarily on private long-term care insurance, Medicare (for rehabilitation stays) or Medicaid (for long-term stays if you have few assets). In some cases, the resident pays entirely out of pocket. If you’re likely to run out of money or insurance coverage during your stay, make sure the home accepts Medicaid. Some won’t admit Medicaid enrollees unless they start out paying for the care themselves.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

Deciding when, or whether, to buy long-term care insurance can be complex. Here’s what to know.If you’re wealthy, you’ll be able to afford help in your home or care in an assisted-living facility or a nursing home. If you’re poor, you can turn to Medicaid for nursing homes or aides at home. But if you’re middle class, you’ll have a thorny decision to make: whether to buy long-term care insurance. It’s a more complex decision than for other types of insurance because it’s very difficult to accurately predict your finances or health decades into the future.What’s the difference between long-term care insurance and medical insurance?Long-term care insurance is for people who may develop permanent cognitive problems like Alzheimer’s disease or who need help with basic daily tasks like bathing or dressing. It can help pay for personal aides, adult day care, or institutional housing in an assisted-living facility or a nursing home. Medicare does not cover such costs for the chronically ill.How does it work?Policies generally pay a set rate per day, week or month — say, up to $1,400 a week for home care aides. Before buying a policy, ask which services it covers and how much it pays out for each kind of care, such as a nursing home, an assisted-living facility, a home personal care service or adult day care. Some policies will pay family members who are providing the care; ask who qualifies as a family member and if the policy pays for their training.You should check to see if benefits are increased to take inflation into account, and by how much. Ask about the maximum amount the policy will pay out and if the benefits can be shared by a domestic partner or spouse.How much does it cost?In 2022, a 60-year-old man buying a $165,000 policy would typically pay about $2,525 annually for a policy that grew at 3 percent a year to take inflation into account, according to a survey by the American Association for Long-Term Care Insurance, a nonprofit that tracks insurance rates. A woman of the same age would pay $3,300 for the same policy because women tend to live longer and are more likely to use it. The higher the inflation adjustment, the more the policy will cost.If a company has been paying out more than it anticipated, it’s more likely to raise rates. Companies need the approval of your state’s regulators, so you should find out if the insurer is asking the state insurance department to increase rates for the next few years — and if so, by how much — since companies can’t raise premiums without permission. You can find contacts for your state’s insurance department through the National Association of Insurance Commissioners’ directory.Should I buy it?It’s probably not worth the cost if you don’t own your home or have a significant amount of money saved and won’t have a sizable pension beyond Social Security. If that describes you, you’ll probably qualify for Medicaid once you spend what you have. But insurance may be worth it if the value of all your savings and possessions excluding your primary home is at least $75,000, according to a consumers’ guide from the insurance commissioners’ association.Even if you have savings and valuable things that you can sell, you should think about whether you can afford the premiums. While insurers can’t cancel a policy once they’ve sold it to you, they can — and often do — raise the premium rate each year. The insurance commissioners’ group says you probably should consider coverage only if it’s less than 7 percent of your current income and if you can still pay it without pain if the premium were raised by 25 percent.Many insurers are selling hybrid policies that combine life insurance and long-term care insurance. Those are popular because if you don’t use the long-term care benefit, the policy pays out to a beneficiary after you die. But compared with long-term care policies, hybrid policies “are even more expensive, and the coverage is not great,” said Howard Bedlin, government relations and advocacy principal at the National Council on Aging.When should I buy a policy?Wait too long and you may have developed medical conditions that make you too risky for any insurer. Buy too early and you may be diverting money that would be better invested in your retirement account, your children’s tuition or other financial priorities. Jesse Slome, executive director of the American Association for Long-Term Care Insurance, says the “sweet spot” is when you’re between the ages of 55 and 65. People younger than that often have other financial priorities, he said, that make the premiums more painful.When can I tap the benefits?Make sure you know which circumstances allow you to draw benefits. That’s known as the “trigger.” Policies often require proof that you need help with at least two of the six “activities of daily living,” which are: bathing, dressing, eating, being able to get out of bed and move, continence, and being able to get to and use the toilet. You can also tap your policy if you have a diagnosis of dementia or some other kind of cognitive impairment. Insurance companies will generally send a representative to do an evaluation, or require an assessment from your doctor.Many policies won’t start paying until after you’ve paid out of your own pocket for a set period, such as 20 days or 100 days. This is known as the “elimination period.”Jordan Rau is a senior reporter with KFF Health News, which is part of the organization formerly known as the Kaiser Family Foundation.

Assisted-living centers have become an appealing retirement option for hundreds of thousands of boomers who can no longer live independently, promising a cheerful alternative to the institutional feel of a nursing home.But their cost is so crushingly high that most Americans can’t afford them.These highly profitable facilities often charge $5,000 a month or more and then layer on extra fees at every step. Residents’ bills and price lists from a dozen facilities offer a glimpse of the charges: $12 for a blood pressure check; $50 per injection (more for insulin); $93 a month to order medications from a pharmacy not used by the facility; $315 a month for daily help with an inhaler.The facilities charge extra to help residents get to the shower, bathroom or dining room; to deliver meals to their rooms; to have staff check-ins for daily “reassurance” or simply to remind residents when it’s time to eat or take their medication. Some even charge for routine billing to a resident’s insurance for care.“They say, ‘Your mother forgot one time to take her medications and so now you’ve got to add this on and we’re billing you for it,’” said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care, a nonprofit.About 850,000 older Americans reside in assisted-living facilities, which have become one of the most lucrative branches of the long-term care industry catering to people 65 and older. Investors, regional companies and international real estate trusts have jumped in: Half of operators in the business of assisted living earn returns of 20 percent or more than it costs to run the sites, an industry survey shows. That is far higher than the money made in most other health sectors.Rents are often rivaled or exceeded by charges for services, which are either packaged in a bundle or levied à la carte. Overall prices have been rising faster than inflation, and rent increases since the start of last year have been higher than at any previous time since at least 2007, according to the National Investment Center for Seniors Housing & Care, which provides data and other information to companies.There are now 31,000 assisted-living facilities nationwide — twice the number of skilled nursing homes. Four of every five facilities are run as for-profits. Members of racial or ethnic groups account for only a tenth of residents, even though they make up a quarter of the population of people 65 or older in the United States.A public opinion survey conducted by KFF, the organization formerly known as the Kaiser Family Foundation, found that 83 percent of adults said it would be impossible or very difficult to pay $60,000 a year for an assisted-living facility. Almost half of those surveyed who either lived in a long-term care residence or had a loved one who did encountered unexpected add-on fees for things they assumed were included in the price.Poll shows about half dissatisfied with the cost of a long-term care facility for themselves or a loved oneMost were satisfied with the quality of care, but about half were not satisfied with the cost. Almost half reported unexpected charges.

Note: Responses are from U.S. adults who had direct experience as a resident in a nursing home, assisted living or other long-term care facility in the last two years or had a family member with such experience.Source: 2022 KFF survey on affordability of long-term care in the U.S.By Albert SunAssisted living is part of a broader affordability crisis in long-term care for the swelling population of older Americans. Over the past decade, the market for long-term care insurance has virtually collapsed, covering just a tiny portion of older people. Home health workers who can help people stay safely in their homes are generally poorly paid and hard to find.Jon Guckenberg with his legal guardian, Nancy Pilger, in his room at New Perspective Cloquet, in Minnesota.Tim Gruber for The New York TimesMr. Guckenberg’s rent for a single room was $4,140 a month before adding in a raft of other charges.Tim Gruber for The New York TimesAnd even older people who can afford an assisted-living facility often find their life savings rapidly drained.Unlike most residents of nursing homes where care is generally paid for by Medicaid, the federal-state program for the poor and disabled, assisted-living residents or their families usually must shoulder the full costs. Most centers require those who can no longer pay to move out.The industry says its pricing structures pay for increased staffing that helps more infirm residents and avoids saddling others with costs of services they don’t need.Prices escalate greatly when a resident develops dementia or other serious illnesses. At one facility in California, the monthly cost of packages for people with dementia or other cognitive issues increased from $1,325 for those requiring the least amount of help to $4,625 as residents’ needs grew.“It’s profiteering at its worst,” said Mark Bonitz, who explored multiple places in Minnesota for his mother, Elizabeth. “They have a fixed amount of rooms,” he said. “The way you make the most money is you get so many add-ons.” Last year, he moved his mother to a nonprofit center, where she lived until her death in July at age 96.LaShuan Bethea, executive director of the National Center for Assisted Living, a trade association of owners and operators, said the industry would require financial support from the government and private lenders to bring prices down.“Assisted-living providers are ready and willing to provide more affordable options, especially for a growing elderly population,” Ms. Bethea said. “But we need the support of policymakers and other industries.” She said offering affordable assisted living “requires an entirely different business model.”Others defend the extras as a way to appeal to the waves of boomers who are retiring. “People want choice,” said Beth Burnham Mace, a special adviser for the National Investment Center for Seniors Housing & Care. “If you price it more à la carte, you’re paying for what you actually desire and need.”Yet residents don’t always get the heightened attention they paid for. Class-action lawsuits have accused several assisted-living chains of failing to raise staffing levels to accommodate residents’ needs or of failing to fulfill billed services.“We still receive many complaints about staffing shortages and services not being provided as promised,” said Aisha A. Elmquist, until recently the deputy ombudsman for long-term care in Minnesota, a state-funded advocate. “Some residents have reported to us they called 911 for things like getting in and out of bed.”‘Can You Find Me a Money Tree?’Mr. Reiners with his daughter and a nursing aide at his room at the Waters in March, before he had to move to a less expensive facility.Tim Gruber for The New York TimesFlorence Reiners, 94, adores living at the Waters of Excelsior, an upscale assisted-living facility in the Minneapolis suburb of Excelsior. The 115-unit building has a theater, a library, a hair salon and a spacious dining room.“The windows, the brightness and the people overall are very cheerful and very friendly,” Mrs. Reiners, a retired nursing assistant, said. Most important, she was just a floor away from her husband, Donald, 95, a retired water department worker who served in the military after World War II and has severe dementia.She resisted her children’s pleas to move him to a less expensive facility available to veterans.Mrs. Reiners is healthy enough to be on a floor for people who can live independently, so her rent is $3,330 plus $275 for a pendant alarm. When she needs help, she’s billed an exact amount, like a $26.67 charge for the 31 minutes an aide spent helping her to the bathroom one night.Her husband’s specialty care at the facility cost much more, at $6,150 a month on top of $3,825 in rent.Month by month, their savings, mainly from the sale of their home, and monthly retirement income of $6,600 from Social Security and his municipal pension, dwindled. In three years, their assets and savings dropped to about $300,000 from around $550,000.Her children warned her that she would run out of money if her health worsened. “She about cried because she doesn’t want to leave her community,” Anne Palm, one of her daughters, said.In June, Mrs. Reiners relented and they moved her husband to the V.A. home across the city. His care costs $3,900 a month, 60 percent less than at the Waters. But Mrs. Reiners is not allowed to live at the veterans’ home.After nearly 60 years together, she was devastated. When an admissions worker asked her if she had any questions, she answered, “Can you find me a money tree so I don’t have to move him?”Heidi Elliott, vice president for operations at the Waters, said employees carefully reviewed potential residents’ financial assets with them, and explained how costs can increase over time.“Oftentimes, our senior living consultants will ask, ‘After you’ve reviewed this, Mr. Smith, how many years do you think Mom is going to be able to, to afford this?’” she said. “And sometimes we lose prospects because they’ve realized: ‘You know, what? Nope, we don’t have it.’”Florence and Donald Reiners used to live a floor apart, but with the cost of his specialty care, Mr. Reiners had to move to a separate facility.Tim Gruber for The New York TimesMr. Reiners moved to a V.A. home across the city, but his wife is not allowed to live at the veterans’ facility. Tim Gruber for The New York TimesPotential Buyers From the BahamasFor residents, the median annual price of assisted living has increased 31 percent faster than inflation, nearly doubling from 2004 to 2021, to $54,000, according to surveys by the insurance firm Genworth. Monthly fees at memory care centers, which specialize in people with dementia and other cognitive issues, can exceed $10,000 in areas where real estate is expensive or the residents’ needs are high.Diane Lepsig, president of CarePatrol of Bellevue-Eastside, in the Seattle suburbs, which helps place people, said that she warned those seeking advice that they should expect to pay at least $7,000 a month. “A million dollars in assets really doesn’t last that long,” she said.Prices rose even faster during the pandemic as wages and supply costs grew. Brookdale Senior Living, one of the nation’s largest assisted-living owners and operators, reported to stockholders rate increases that were higher than usual for this year. In its assisted-living and memory care division, Brookdale’s revenue per occupied unit rose 9.4 percent in 2023 from 2022, primarily because of rent increases, financial disclosures show.In a statement, Brookdale said it worked with prospective residents and their families to explain the pricing and care options available: “These discussions begin in the initial stages of moving in but also continue throughout the span that one lives at a community, especially as their needs change.”Many assisted-living facilities are owned by international real estate investment trusts. Their shareholders expect the high returns that are typically gained from housing investments rather than the more marginal profits of the heavily regulated health care sector. Even during the pandemic, earnings remained robust, financial filings show.Ventas, a publicly traded real estate investment trust, reported earning revenues in the third-quarter of this year that were 24 percent above operating costs from its investments in 576 senior housing properties, which include those run by Atria Senior Living and Sunrise Senior Living.Ventas said the prices for its services were affordable. “In markets where we operate, on average it costs residents a comparable amount to live in our communities as it does to stay in their own homes and replicate services,” said Molly McEvily, a spokeswoman.In the same period, Welltower, another large real estate investment trust, reported a 24 percent operating margin from its 883 senior housing properties, which include ones operated by Sunrise, Atria, Oakmont Management Group and Belmont Village. Welltower did not respond to requests for comment.The median operating margin for assisted-living facilities in 2021 was 23 percent if they offered memory care and 20 percent if they didn’t, according to David Schless, chief executive of the American Seniors Housing Association, a trade group that surveys the industry each year.Ms. Bethea said those returns could be invested back into facilities’ services, technology and building updates. “This is partly why assisted living also enjoys high customer satisfaction rates,” she said.Brandon Barnes, an administrator at a family business that owns three small residences in Esko, Minn., said he and other small operators had been approached by brokers for companies, including one based in the Bahamas. “I don’t even know how you’d run them from that far away,” he said.Rating the Cost of a Shower, on a Point ScaleCharles Barker with his daughter, Celenie Singley. Ms. Singley moved her father from one memory care unit to another after she had safety concerns about the facility. Ariana Drehsler for The New York TimesTo consistently get such impressive returns, some assisted-living facilities have devised sophisticated pricing methods. Each service is assigned points based on an estimate of how much it costs in extra labor, to the minute. When residents arrive, they are evaluated to see what services they need, and the facility adds up the points. The number of points determines which tier of services you require; facilities often have four or five levels of care, each with its own price.Charles Barker, an 81-year-old retired psychiatrist with Alzheimer’s, moved into Oakmont of Pacific Beach, a memory care facility in San Diego, in November 2020. In the initial estimate, he was assigned 135 points: 5 for mealtime reminders; 12 for shaving and grooming reminders; 18 for help with clothes selection twice a day; 36 to manage medications; and 30 for the attention, prompting and redirection he would need because of his dementia, according to a copy of his assessment provided by his daughter, Celenie Singley.Mr. Barker’s points fell into the second-lowest of five service levels, with a charge of $2,340 on top of his $7,895 monthly rent.Ms. Singley became distraught over safety issues that she said did not seem as important to Oakmont as its point system. She complained in a May 2021 letter to Courtney Siegel, the company’s chief executive, that she repeatedly found the doors to the facility, located on a busy street, unlocked — a lapse at memory care centers, where secured exits keep people with dementia from wandering away. “Even when it’s expensive you really don’t know what you’re getting,” she said in an interview.Ms. Singley, 50, moved her father to another memory care residence. Oakmont did not respond to requests for comment.Other residents and their families brought a class-action lawsuit against Oakmont in 2017 that said the company, an assisted-living and memory care provider based in Irvine, Calif., had not provided enough staffing to meet the needs of residents identified by its own assessments.Jane Burton-Whitaker, a plaintiff who moved into Oakmont of Mariner Point in Alameda, Calif., in 2016, paid $5,795 monthly rent and $270 a month for assistance with her urinary catheter, but sometimes the staff would empty the bag just once a day when it required multiple changes, the lawsuit said.She paid another $153 a month for checks of her “fragile” skin “up to three times a day, but most days staff did not provide any skin checks,” according to the lawsuit. (Skin breakdown is a hazard for older people that can lead to bedsores and infections.) Sometimes it took the staff 45 minutes to respond to her call button, so she left the facility in 2017 out of concern she would not get attention should she have a medical emergency, the lawsuit said.Oakmont paid $9 million in 2020 to settle the class-action suit and agreed to provide enough staffing, without admitting fault.Similar cases have been brought against other assisted-living companies. In 2021, Aegis Living, a company based in Bellevue, Wash., agreed to a $16 million settlement, in a case claiming that its point system — which charged 64 cents per point per day — was “based solely on budget considerations and desired profit margins.” Aegis did not admit fault in the settlement or respond to requests for comment.When the Money Is GoneMr. Guckenberg ran through his life savings a year after moving into his assisted-living facility.Tim Gruber for The New York TimesJon Guckenberg’s rent for a single room in an assisted-living cottage in rural Minnesota was $4,140 a month before adding in a raft of other charges.The facility, New Perspective Cloquet, charged him $500 to reserve a spot and a $2,000 “entrance fee” before he set foot inside two years ago. Each month, he also paid $1,080 for a care plan that helped him cope with bipolar disorder and kidney problems, $750 for meals and another $750 to make sure he took his daily medications. Cable service in his room was an extra $50 a month.A year after moving in, Mr. Guckenberg, 83, a retired pizza parlor owner, had run through his life’s savings and was put on a state health plan for the poor.Doug Anderson, a senior vice president at New Perspective, said in a statement that “the cost and complexity of providing care and housing to seniors has increased exponentially due to the pandemic and record-high inflation.”In one way, Mr. Guckenberg has been luckier than most people who run out of money to pay for their care. His residential center accepts Medicaid to cover his health services.Most states have similar programs, though a resident must be frail enough to qualify for a nursing home before Medicaid will cover the health care costs in an assisted-living facility. But enrollment is restricted. In 37 states, people are on waiting lists for months or years.“We recognize the current system of having residents spend down their assets and then qualify for Medicaid in order to stay in their assisted-living home is broken,” Ms. Bethea, with the trade association, said. “Residents shouldn’t have to impoverish themselves in order to continue receiving assisted-living care.”Only 18 percent of residential care centers agree to take Medicaid payments, which tend to be lower than what they charge self-paying clients, according to a federal survey of facilities. And even places that accept Medicaid often limit coverage to a minority of their beds.For those with some retirement income, Medicaid isn’t free. Nancy Pilger, Mr. Guckenberg’s guardian, said that he was able to keep only about $200 of his $2,831 monthly retirement income, with the rest going to paying rent and a portion of his costs covered by the government.In September, Mr. Guckenberg moved to a nearby assisted-living building run by a nonprofit. Ms. Pilger said his costs were the same. But for other residents who have not yet exhausted their assets, Mr. Guckenberg’s new home charges $12 a tray for meal delivery to the room; $50 a month to bill a person’s long-term care insurance plan; and $55 for a set of bed rails.Even after Mr. Guckenberg had left New Perspective, however, the company had one more charge for him: a $200 late payment fee for money it said he still owed.Jordan Rau is a senior reporter for KFF Health News, which is part of the organization formerly known as Kaiser Family Foundation.

The facilities can look like luxury apartments or modest group homes, and can vary in pricing structures. Here’s a guide.Are you confused about what an assisted-living facility is, and how it differs from a nursing home? And what you can expect to pay? Here’s a guide to this type of housing for older people.What is assisted living?Assisted-living facilities occupy the middle ground of housing for people who can no longer live independently but don’t need the full-time medical supervision provided at a nursing home. They might be right for those who have trouble moving about, bathing, eating or dressing, or who have Alzheimer’s disease or other forms of dementia.Assisted-living facilities can look like luxury apartments or modest group homes, but they are staffed with aides who can help residents take a shower, get out of bed, get to the dining room, take medications, or help with other daily tasks and needs. Meals, activities and housekeeping are usually provided. Some facilities have trained nurses on-site, but in many states the facilities are not required to have them at the ready, or at all. Popular buildings — or specialized units within them, such as ones for dementia — have waiting lists.“The key is to start early,” said Eilon Caspi, an assistant research professor at the University of Connecticut. “You don’t want to wait for the crisis and then have 24 hours to make a decision.”We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.We are confirming your access to this article, this will take just a moment. However, if you are using Reader mode please log in, subscribe, or exit Reader mode since we are unable to verify access in that state.Confirming article access.If you are a subscriber, please 

Most countries spend more than the United States on care, but middle class and affluent people still bear a substantial portion of the costs.Around the world, wealthy countries are struggling to afford long-term care for rapidly aging populations. Most spend more than the United States through government funding or insurance that individuals are legally required to obtain. Some protect individuals from exhausting all their income or wealth paying for long-term care. But as in the United States, middle-class and affluent individuals in many countries can bear a substantial portion of the costs.The U.S. spends less as a share of G.D.P. on long-term care than most other wealthy countries

Notes: Figures show government funding and compulsory insurance spending on long-term care as a percentage of gross domestic product. Figures are for 2021 spending for all countries except Japan and Australia, which use 2020 figures.Source: Organization for Economic Cooperation and DevelopmentBy The New York TimesHere’s how five other countries pay for long-term care.🇯🇵JAPAN. Long-term care insurance is mandatory for Japanese citizens age 40 and over, while in the United States only a small portion of people voluntarily obtain coverage. Half the funding for Japan’s program comes from tax revenues and half from premiums. Older adults contribute 10 to 30 percent of the cost of services, depending on their income, and insurance picks up the rest. There is a maximum amount people have to spend from their income before the insurance covers the remainder of the cost. Workers can also take up to 93 days of paid leave to help relatives with long-term care needs. Japan assigns a care manager to each person using services; each manager oversees about 40 older adults. In 2020, Japan spent 2 percent of its gross domestic product on long-term care, 67 percent more than the United States spent that year.🇳🇱THE NETHERLANDS. The Dutch have included long-term care in their universal health care system since 1968. One public insurance program pays for nursing homes and other institutional settings, and another pays for nursing and personal care at home. Enrollment is mandatory. Dutch taxpayers contribute nearly 10 percent of their income toward insurance premiums, up to a set amount. Out-of-pocket payments amount to about 7 percent of the cost of institutional care. General taxes pay for a third program in which municipalities provide financial assistance and social support for older people living at home. There is no private long-term care insurance. The Netherlands spent 4.1 percent of its gross domestic product on long-term care in 2021, more than any other country tracked by the Organization for Economic Cooperation and Development, and four times the amount the United States spent.🇨🇦CANADA. Provinces and territories fund long-term care services through general tax revenue. Money budgeted is not always enough to cover all services, and some localities give priority to those with the greatest needs. The amount of subsidies people can receive, the costs they have to pay out of pocket and the availability of services vary by province and territory, as they do in the United States with state Medicaid programs. The mix of providers also varies regionally: For instance, nursing home care in Quebec is mostly run by a public system while homes in Ontario are mostly for-profit. Notably, Canada’s long-term care system is separate from its national health care system, which pays for hospitals and doctors with no out-of-pocket costs to patients. In 2021, Canada spent 1.8 percent of its G.D.P. on long-term care, 80 percent more than the United States spent.🇬🇧BRITAIN. Local authorities pay for most long-term care through taxes and central government grants. Private providers usually supply services. Government contributions are based on financial need, with co-payments usually required. As in the United States, middle-class and wealthy people pay most or all of the costs themselves. Unlike in the United States, the government provides payments directly to lower-income people so they can hire workers to care for them in their homes. Britain has also taken steps to shield people from losing all of their wealth to pay for long-term care. It subsidizes care for people with savings and property of less than about $30,000, while in the United States most people don’t qualify for Medicaid until they have run through all but $2,000 to $3,000 of their assets. In 2022, the government proposed extending subsidies to people who have as much as $105,000 of wealth and property, with a lifetime cap of about $100,000 on how much anyone spends on long-term medical care, excluding room and board in a nursing home. But the plan has been postponed to 2025. In 2021, Britain spent 1.8 percent of its G.D.P. on long-term care, 80 percent more than the United States did.🇸🇬SINGAPORE. Singapore recently instituted a system of mandatory long-term care insurance for those born in 1980 or later. Citizens and permanent residents are automatically enrolled in an insurance plan called CareShield Life starting at age 30. They must pay premiums until they retire or turn 67 (whichever comes later) or are approved to use services. The government subsidizes 20 to 30 percent of premiums for those who earn around $2,000 a month or less. Monthly payouts start at about $440. Government subsidies for nursing homes and other institutional care can range from 10 percent to 75 percent depending on ability to pay. Those who make more than $2,000 a month receive no subsidies. CareShield is optional for Singaporeans born in 1979 or earlier; they are covered under an older, voluntary plan. Singapore also provides a means-tested monthly cash grant — this year about $290 — to help with caregiving expenses.Sources: The National Bureau of Economic Research project on international comparisons of long-term care; Kathleen McGarry, an economics professor at UCLA; The Commonwealth Fund; Organization for Economic Cooperation and Development; government websites.Note: Spending comparisons with the United States are based on the most recent O.E.C.D. data and include spending from government and compulsory insurance programs as a percent of each country’s gross domestic product, which is the total monetary value of all the finished goods and services produced within a country’s borders. The comparisons cover people of all ages and exclude spending from voluntary insurance plans and out-of-pocket costs. All currency figures are in U.S. dollars.Jordan Rau is a reporter for KFF Health News, a part of the organization formerly known as the Kaiser Family Foundation.

Citing worker shortages, nursing home operators said the standard could not be met without additional funding for higher wages.The nation’s most thinly staffed nursing homes would be required to hire more workers under new rules proposed on Friday by the Biden administration, the greatest change to federal nursing home regulations in three decades.The proposed standard was prompted by the industry’s troubled performance earlier in the coronavirus pandemic, when 200,000 nursing home residents died. But the proposal falls far short of what both the industry and patient advocates believe is needed to improve care for most of the 1.2 million Americans in nursing homes.The proposal, by the Centers for Medicare and Medicaid Services, would require all facilities to increase staff up to certain minimum levels, but it included no money for nursing homes to pay for the new hires.C.M.S. estimated that three-quarters of the nation’s 15,000 homes would need to add staff members. But the increases at many of those facilities would be minor, as the average nursing home already employs nurses and aides at, or very close to, the proposed levels.The government said it would exempt nursing homes from punishment if they could prove that there was a local worker shortage and that the facilities had made sincere efforts to recruit employees.“Fundamentally, this standard is wholly inadequate to meet the needs of nursing home residents,” said Richard Mollot, the executive director of the Long Term Care Community Coalition, an advocacy group based in New York.Executives in the nursing home industry said that without extra money from Medicare or Medicaid — the two federal insurers that pay for most nursing home care — the requirement would be financially unattainable.“It’s meaningless to mandate staffing levels that cannot be met,” Katie Smith Sloan, the president and chief executive of LeadingAge, an association that includes nonprofit nursing homes, said in a statement. “There are simply no people to hire — especially nurses. The proposed rule requires that nursing homes hire additional staff. But where are they coming from?”The new staffing standard would require homes to have daily average nurse staffing levels amounting to at least 0.55 hours per resident. That translates to one registered nurse for every 44 residents. But that is below what the average nursing home already provides, which is 0.66 hours per resident, a 1:36 ratio, federal records show.At least one registered nurse would have to be on duty at all times under the proposed plan — one of the biggest changes for the facilities, as they currently must have nurses for only eight consecutive hours each day.The proposed rule also calls for 2.45 nurse aide hours per resident per day, meaning a ratio of about one aide for every 10 residents. While the federal government sets no specific staffing requirements for nurse aides, the average home already provides 2.22 nurse aide hours a day, a ratio of about 1:11.“The federal minimum staffing standards proposed by C.M.S. are robust yet achievable,” the agency said in a statement. “The proposal also makes clear that the numerical staffing levels are a floor — not a ceiling — for safe staffing.”Registered nurses are at the top of the chain of command at nursing homes, overseeing assessments of residents and handling complex clinical tasks. Nurses delegate more straightforward clinical roles to licensed practical nurses.Certified nurse assistants, often called nurse aides, are generally the most plentiful in a nursing home and help residents with basic needs like bathing, getting out of bed and eating.On average, registered nurses make $37 an hour while licensed practical nurses earn $28 an hour, according to C.M.S. Aides often start at minimum wage or slightly above, earning $17 an hour on average.“People have more choice,” said Tina Sandri, the chief executive of Forest Hills of DC, a nursing home in Washington, referring to nursing home staff. “They can go to hospitals and make more and do less than they do here in a nursing home.”“We’ve lost staff to hospitals that had $20,000 signing bonuses,” she added, “and as a nonprofit, we can’t compete with that.”Nursing home officials say they cannot afford to pay higher wages because state Medicaid programs reimburse them too little. Patient advocates, however, note that some for-profit homes are providing substantial returns to investors.Medicare and Medicaid spent $95 billion on nursing home care and retirement community care in 2021, according to C.M.S. The agency estimated that the new standards would cost homes another $4 billion in three years, when all homes except those in rural areas would need to comply. Rural homes would have five years.Ellen Quirk, a retired certified nurse assistant in Hayes, Va., recalled that sometimes she would care for all of the residents on a single floor in the nursing home, which could be 20 or more people, by herself. It’s challenging for an aide to care for more than five to seven people at a time, she said.“If it’s more than that, then things aren’t done properly,” Ms. Quirk, 63, said. “Things are skipped over, like a bath or changing them every couple of hours or feeding them properly.”“I’ve seen patients that roll over and fall out of bed,” she added. “Sometimes they get bed sores because beds are saturated in urine for hours and hours.”The nursing home industry has been pressing federal and state governments to pay for a bevy of enticements to long-term care workers, including educational subsidies for those who have worked in nursing homes, loan forgiveness and career opportunities for certified nursing assistants working toward their nursing degrees.The administration said it would offer $75 million in scholarships and tuition as part of the new proposal. The administration is accepting comments for the next 60 days before it finalizes the new standard.