Despite CMS' federal vaccine mandate, many health care workers remain unvaccinated—including a significant number of nursing home workers who have sought out potentially unwarranted medical exemptions, Emily Hopkins and Andrea Suozzo report for ProPublica.
Under CMS' vaccine mandate, which went into effect earlier this year, health care facilities that participate in Medicare or Medicaid are required to vaccinate their workers against Covid-19.
In guidance documents, the agency said health care workers would be required to get their first dose of a Covid-19 vaccine by Feb. 14 and their last primary dose by March 15. Health care facilities were also required to demonstrate they developed policies and procedures to ensure all employees have received at least one shot of a Covid-19 vaccine by Feb. 14.
Currently, CDC data shows that around 1.7 million out of 1.9 million nursing home workers across more than 15,000 facilities have been fully vaccinated. Of these workers, more than 500,000 were vaccinated after CMS' mandate went into effect, ultimately raising the overall vaccination rate in this group from 65% in September 2021 to 89% in late March.
However, vaccination rates among nursing home staff vary by both state and facility. For example, nursing homes in Rhode Island have a 99% staff vaccination rate, but nursing homes in Montana only have a 77% vaccination rate.
According to CDC data, one-in-six nursing homes have fewer than 75% of their workers vaccinated against Covid-19. Under CMS' mandate, facilities with unvaccinated workers will face escalating penalties with a loss of federal funding as a "final measure."
Although many health care workers have gotten vaccinated due to federal mandate, others have sought exemptions to the requirement. In particular, many have sought after and been granted religious exemptions to the requirement.
Aside from religious exemptions, a significant number of workers have been granted medical exemptions—even though CDC said only those with life-threatening allergies to the Covid-19 vaccines or one of their ingredients should avoid getting vaccinated. As of late March, almost 20,000 nursing home workers had medical exemptions, up from around 9,400 when the mandate was first announced.
Many of the employees claiming medical exemptions are also clustered in the same nursing homes, Hopkins and Suozzo write. For example, 27 nursing facilities in Ohio have over 15% of their employees claiming medical exemptions, more than any other state. Similarly, more than a dozen facilities in California, where only 4% of the state's nursing home workers are unvaccinated, have reported a third to half of their staff members have a medical reason that prevents them from getting vaccinated.
According to Tim Leslie, a researcher at George Mason University who has studied vaccination rates, these clusters have raised questions among scientists since they "suggest some level of organization to achieve that outcome."
Separately, Jana Shaw, a pediatric infectious disease specialist at SUNY Upstate Medical University who studies vaccine hesitancy, said she believed these medical exemptions are being abused. "Previous research has shown, as we started mandating vaccinations, people will find avenues to get out of the obligation of getting vaccinated," she said.
So far, at least one nursing facility has been cited by state regulators for having a staff member claim a false medical reason to avoid the vaccine mandate. At Premier Washington Health Center in Pennsylvania, an employee received a medical exemption for multiple sclerosis even those it is not on CDC's list of qualifying conditions. The employee later received a different exemption, according to the state inspection report.
For its part, CMS said it "remains pleased by progress to-date" in nursing homes and that the goal is to help facilities come into compliance with the mandate rather than disciplining them.
In addition, the agency said while exemptions "could be appropriate in certain limited circumstances ... [n]o exemption should be provided to any staff for whom it is not legally required or who requests an exemption solely to evade vaccination."
In a statement, the American Health Care Association/National Center for Assisted Living, said nursing homes are dedicated to getting their staff vaccinated and that unvaccinated workers must take precautions to reduce the risk of infection.
"Each hesitant staff member has their own unique reason(s) for choosing not to get the vaccine,” the statement said. "Despite rampant misinformation spreading online, the industry has made significant progress. We have found that it takes a multi-pronged, persistent approach to help increase vaccination rates." (Hopkins/Suozzo, ProPublica, 4/21)
The recent report from ProPublica highlights uneasy realities for the nursing home industry. According to medical experts, few true reasons exist for claiming a medical exemption. It is odd and potentially worrisome that there are so many exemptions being claimed in the nursing home workforce. It's uncomfortable to try to dig deeper into these exemptions, however, because each individual has different circumstances, and that must be respected—but also because, frankly, nursing homes need the staff.
With potential staffing mandates coming within the next year to Medicare- and Medicaid-funded facilities, it's a critical time for nursing home leaders to maintain or increase their staffing levels. And despite the troubling amount of potentially inaccurate medical exemptions, cases and death rates per 1,000 residents are at their near lowest level since the start of the pandemic.
But nursing homes still house the population most at risk to the spread of Covid-19, and there are incoming factors that are cause for concern. While 89% of staff have been fully vaccinated (completed the single- or dual-shot series last spring), only 44% have gotten their booster as of March 27th. As efficacy of the vaccines decreases over time, this leaves staff vulnerable. Plus, the report of a new, highly transmissible omicron variant is stoking fears of a looming surge.
Many nursing homes are considering re-introducing vaccine drives to encourage staff to get their boosters. Leaders must encourage vaccine and booster uptake now like they did when vaccines were first rolled out and encourage staff to get their shots.
As always, leaders need to remember that each individual staff member deserves respect and understanding, and leaders should approach the conversation with empathy—while keeping in mind the need to protect the larger community.
To learn how to allay staff fears and encourage them to get the vaccine, access our work on vaccine hesitancy for long-term care leaders.
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