The COVID pandemic devastated nursing homes. People living in long-term care facilities represent less than 1 percent of the U.S. population but account for a third of its COVID deaths: more than 174,000 people as of early March. And it wasn't just residents—nursing home workers had one of the deadliest jobs last year.

Problems with long-term care precede COVID. Most Americans say they want to remain at home as long as possible as they age, yet many cannot afford such care and wind up in a nursing facility. Such facilities can cost hundreds of dollars a day. Medicaid covers most charges, yet people must be nearly bankrupt to qualify. The program reimburses nursing homes only for 70 to 80 percent of those costs, so it is harder for them to provide quality care.

Most nursing homes are for-profit, and private equity firms are increasingly gobbling them up to make a buck at the expense of residents. Certified nursing assistants (CNAs), who furnish the bulk of care in nursing homes, earn only about $14 an hour; recruiting and retaining them is a huge challenge. And the current U.S. government system for evaluating nursing facilities—the so-called five-star rating system—is largely based on self-reported data that are easy to manipulate, and independent inspections often fail to flag serious violations in the quality of care, according to a recent New York Times investigation.

“This isn't just a bad-actor problem,” says David Grabowski, a professor of health-care policy at Harvard Medical School. “It's the system that's broken.”

How to fix it? President Joe Biden's proposed $2-trillion infrastructure bill offers a promising start toward helping people age at home. The bill includes $400 billion over eight years for home- and community-based care. It expands Medicaid coverage for such services, which states are not currently required to provide (and those that do often have long waiting lists). The bill, which faces steep opposition from Republicans, also aims to establish more and better-paying jobs for home health workers and to give them the ability to join unions and collectively bargain.

These steps are a good beginning, but they don't do anything to help nursing homes. “Nursing homes must be prioritized at the level of other medical facilities,” says Lori Porter, CEO of the National Association of Health Care Assistants, which represents CNAs. “We're taking care of the sickest people in America.”

The American Health Care Association (AHCA), a nonprofit that represents nursing homes and other assisted living facilities, and LeadingAge, an association of nonprofit aging service providers, recently released a proposal dubbed the Care for Our Seniors Act. The plan would require at least one registered nurse on duty 24 hours a day at every facility (in addition to CNAs and other staff) and a 30-day supply of personal protective equipment. The act includes provisions to attract and retain employees, such as providing loan forgiveness for new graduates working in long-term care, tax credits for employees, and support for child care and affordable housing. And it aims to create better oversight of facilities by focusing more on improving them than punishing them and by closing chronically poor performers. Most nursing homes are badly outdated; the new proposal calls for renovating them and ensuring all residents have private rooms. AHCA says its plan will cost $15 billion a year. To pay for it, the proposal calls for several strategies, including increasing the federal government match for Medicaid, which states have underfunded, and mandating that states pay facilities at a rate sufficient for them to break even.

The AHCA-LeadingAge proposal is on the right track, but one thing it's missing is increased accountability, according to Grabowski. “There's a lot of skepticism that all those dollars are going to find their way to their intended purposes,” he says. Beyond top-level reforms, Porter wants to empower nursing home residents and their families to fight for the care they or their loved ones deserve. Taking a tour of a nursing home doesn't tell you anything about the quality of care, she says. Instead you should request a meeting with the president of the resident council, an advocacy group consisting of residents and their families—and if one doesn't exist, you can form one. They can tell you whether a facility is really as good as it claims to be.

These changes will show that we, as a society, value elderly lives—including our own.