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Assuring Quality of Care in Nursing Homes

Policy Date: 1/1/1996
Policy Number: 9603

The American Public Health Association,
Knowing that approximately 75% of the nursing facilities in the United States are for profit;1 and
Recognizing that when nursing homes attempt to reduce costs and maximize profits, unwise use of resources and subquality care can result; and
Acknowledging that nationally, approximately 1.5 million disabled and elderly people resided in nursing facilities in 1995, of whom 90% were frail elderly;2 and
Recognizing that nursing home residents are dependent on providers and government for controlling quality of care; and
Knowing that Congress attempted to deter nursing facilities from delivering subquality care by enacting the nursing home reform mandates under the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987), Public Law 100-203, which contained rules mandating that nursing homes provide care to achieve highest practicable well-being for residents, and which became effective October 1, 1990;3,4 and
Acknowledging that the Health Care Financing Administration (HCFA) was given oversight of the implementation of OBRA 1987 nursing home rules; and
Noting that Medicaid plays a fundamental role for institutionalized people, providing nursing home payments on behalf of 1.4 million nursing home residents in 1993, and that each state was responsible for submitting a state Medicaid plan to HCFA that outlined the rules created for implementing the mandates of OBRA 1987; and
Knowing that to date, all of the 50 states have implemented some aspect of OBRA 1987, but that enforcement has been delayed; and
Acknowledging that there have not been many studies conducted to examine the outcomes of these rules and whether there has been an improvement in the provision by nursing homes of care to achieve highest practicable well-being for residents including quality-of-life and biomedical ethics issues;5,6 and
Recognizing that upon review of a sample of national Long Term Care Ombudsman Annual Reports covering the periods 1990 through 1994, the top 10 verified complaints reveal that many quality-of-care problems still exist in spite of OBRA 1987 nursing home reform implementation;7 and
Knowing that the American Public Health Association currently urges presidential veto of any legislation that dismantles the Nursing Home Reform Act regulations;8 and
Acknowledging that Bruce C. Vladeck, administrator at HCFA, mentioned in a press release that the goal of OBRA 1987 nursing home reform was to assure high-quality care for nursing homes;9 and
Understanding that some members of Congress have proposed a set of revisions to the budget plan that would eliminate or seriously weaken the quality of care for nursing home residents, uniform standards for assessments of care and training, and protection against discrimination based on ability to pay and federal enforcement authority; therefore
1. Urges Congress not to enact any legislation that dismantles the Nursing Home Reform Act outlined in the Omnibus Reconciliation Act of 1987, Public Law 100-203 enacted on December 22, 1987;
2. Encourages HCFA to access and analyze data obtained from the Long Term Care Ombudsman and state auditor generals' reports, noting that additional studies by HCFA are not needed;
3. Urges HCFA to move quickly to require and oversee enforcement of the law, with imposition of sanctions at all appropriate levels, for noncompliance; and
4. Urges any compromised Medicaid block grant legislation to mandate continued adherence to OBRA 1987.


  1. Cohen J, Dubay L. The Effects of Medicaid Reimbursement Method and Ownership on Nursing Home Costs, Case Mix, and Stuffing. Inquiry. 1990;27:183-200.

  2. HCIA Inc. and Arthur Andersen & Co; 1994: The Guide to the Nursing Home Industry. Baltimore, MD: HCIA Inc. and Arthur Andersen & Co., 1994.

  3. PL 100-203 Sections 4202 and 4212, 1987.

  4. New APHA policy statements summarized. The Nation's Health. December 1995.

  5. Gertler PJ; Waldman DM. Quality-Adjusted Cost Functions and Policy Evaluation in the Nursing Home Industry. J Political Economy. 1992;100:1232-1256.

  6. Long-Term Care Ombudsman Annual Reports for the Fifty States, 1990-1995.

  7. New APHA policy statements summarized. The Nation's Health. December 1995.

  8. Statement by Bruce C. Vladeck, administrator, Health Care Financing Administration. US Department of Health and Human Services, 1995.

  9. National Citizens' Coalition for Nursing Home Reform, eds. Budget Plan Undermines Federal Nursing Home Standards. Washington, DC: National Citizens' Coalition for Nursing Home Reform; 1995.