Republican Senator Rob Portman from Ohio, the top Republican negotiator on the $1 trillion bipartisan infrastructure package, is seen arriving for the August 10 vote on the bill. Portman was among the Senators who successfully pushed for assisted living facilities' funding to be protected within the bill. (AP Photo/Andrew Harnik)

When a bipartisan group of senators worked to craft an infrastructure bill last month, they came close to taking money away from rural assisted living facilities to help pay for it.

The Infrastructure Investment and Jobs Act was sent to the Senate floor on August 1 and is aiming to provide $1.2 trillion in funding for roads, bridges, public transportation, airports, and other infrastructure needs.  

However, thanks to action by several Congresswomen in rural states, money for assisted living facilities is safe and ready to be allocated, despite being authorized for disbursal more than a year ago. 

Among the sticking points in the negotiations over the infrastructure legislation, according to U.S. Senators Rob Portman (R-Ohio) and Kyrsten Sinema (D-Arizona), was how to pay for it. Republicans insisted that any new funding should be paid for with money already in the budget.

That meant using $210 billion from unused Covid-19 aid programs, the senators said. And as of late July, that had included unused Provider Relief Funds, money allocated through the CARES Act to help assisted living facilities absorb losses due to Covid-19.

Using those funds presented a problem to rural assisted living facilities, said Maggie Elehwany, senior vice president of Public Affairs with Argentum, a non-profit organization representing the interests of long-term care facilities, including assisted living facilities.

“We thought that was really unconscionable at a time when we’ve got these variant cases going up and hospitalizations going up,” Elehwany said. “But moreover, for the assisted living folks that I work with, they have received just a small fraction of what they were supposed to receive from the Provider Relief Fund. They’ve been really underfunded and now half are operating at a loss. They keep being promised that more relief is coming.”

The American Hospital Association, and other healthcare groups,  joined Argentum in opposing the use of Provider Relief Funds to pay for the infrastructure bill, as well as cuts to Medicare and Medicaid.

“Congress recognized that hospitals and health systems needed relief from Medicare cuts during the pandemic and we appreciate the recently provided delay through the end of this year in the two percent mandatory reductions,” a group of nine healthcare organizations wrote to Senate Leaders Chuck Schumer (D-N.Y.) and Mitch McConnell (R-Kentucky).

“Unfortunately, the Bipartisan Infrastructure Framework lists a continuation of mandatory sequestration as an offset for the infrastructure agreement. Medicare funds should not be used to pay for roads and bridges.”

The AHA group argued that additional cuts to the Medicare program were not sustainable and that more funding to combat Covid-19 was needed as the Delta variant threatened communities across the country. Healthcare organizations are still waiting on some of the funds to arrive, they said.

Argentum estimates that through the second quarter of 2021, assisted living facilities in 15 states will lose upwards of $2.4 billion in uncompensated losses due to the Covid-19 pandemic. Personal protective equipment and other costs associated with protecting patients and caregivers are sending these facilities to the brink of financial disaster, Elehwany said.

“During the pandemic, the communities providing assisted living went above and beyond to protect their seniors and caregivers and ensure they had access to the PPE, staffing, care, and services needed to keep people safe,” said James Balda, Argentum president & CEO, in a statement. “Now, without federal intervention, many communities could be at risk of closing due to the steep and uncompensated costs stemming from the pandemic.”  

Nationally, senior living providers have incurred approximately $22.5 billion in losses due to the Covid-19 pandemic. Those losses are expected to grow to nearly $30 billion through the first half of 2021.

Just two percent of the billions allocated to assisted living facilities have been provided to them, Elehwany said.

“Congress appropriated the funds to target frontline caregivers, and to provide them with some relief so they could care for Covid patients and keep vulnerable populations safe,” she said. “A lot of the money went out the door quickly, but the difficulty was that assisted living folks weren’t on the radar to get that funding.”

Part of the problem, she said, was that assisted living facilities and other long-term care facilities don’t get federal dollars through Medicare and Medicaid, which are operated by the U.S. Department of Health and Human Services (HHS).

Rural hospitals and rural nursing homes that had accounts with Medicare and Medicaid saw money deposited directly into their accounts soon after the CARES Act was passed, she said. But those in assisted living facilities, with no ties to the federal government, were forced to wait for months as requirements were laid out for the money they would receive and forms were developed for facilities to apply for the funds.

The lack of help from the federal government, she said, means many assisted living facilities, especially those in rural areas, are facing closure.

“We anticipated the funding coming at the end of last year, and now, here we are… seven months later… still waiting for that (funding) to be released. It’s just so absolutely unbelievable,” Elehwany said.

Battling the Delta Variant

The funding takes on new significance, Elehwany said, as assisted living facilities anticipate another ramping up of expenses facing the Delta variant.

For rural areas already struggling with an insufficient number of places to care for aging populations, further closures of assisted living facilities would only exacerbate the problems, she said.

“The aging population is exploding. In 2034, we’re going to have more older citizens than we have children. That trajectory is only going to continue… In many rural States, (like) West Virginia and rural Pennsylvania, they already have a much older per capita older population,” she said. “There are not enough of these facilities now, and as our population continues to age, there’s no way there’s going to be enough in the future.”

By August 2, Elehwany said, language included in the bill had secured the funding for assisted living facilities, however. The move came from four senators, Senators Susan Collins (R-Maine), Lisa Murkowski (R-Washington), Krysten Sinema (D-Arizona) and Jeanne Shaheen (D-New Hampshire).

Now it’s up to HHS to release those funds, she said.

“HHS is committed to distributing these funds to providers as quickly and equitably as possible to address lost revenues and increased expenses attributable to COVID-19 while maintaining strong safeguards for taxpayer dollars,” the HHS spokesperson said in an email. 

According to the spokesperson, there were $24 billion in unallocated funds from the $178 billion Provider Relief Fund determined by the CARES Act, as well as another $8.5 billion allocated to rural healthcare providers in the American Rescue Plan.