What we know about the impact of Michigan Gov. Whitmer’s nursing home policies

Michigan Gov. Gretchen Whitmer is facing a new wave of criticism over her handling of nursing home residents with COVID-19, after a massive undercounting of deaths from the disease was uncovered in New York.

Under her administration’s policies, hospitals released many elderly, recovering COVID-19 patients back to their long-term care facilities or to nursing homes designated to accommodate them and keep them isolated. In a March 7 interview on CNN, Whitmer said her nursing home policies “actually saved a lot of lives.”

But critics say Whitmer’s policies recklessly exposed other vulnerable nursing home residents to COVID-19 infection. Republican state lawmakers are now calling for state and federal investigations into whether the policies exacerbated the death toll in nursing homes. Their demands have only grown louder after the discovery of a non-disclosure pact in a separation agreement between the state’s former health director and the governor’s office. 

Getting a clear answer on the impact of Whitmer’s policies won’t be easy — and not just because it’s the subject of a pitched partisan battle in Michigan. Health researchers say that because of haphazard data collection during the chaotic onset of the pandemic, they don’t have enough information to conclude definitively whether the returning COVID-19 patients contributed to transmissions at nursing homes. They’re not ruling out that possibility.

But the clues they have point to other factors, including high infection rates in surrounding communities that led to nursing-home staff becoming exposed to the coronavirus and spreading the infection inside the facilities.

The evolution of Whitmer’s orders

Facing a surge in Michigan COVID-19 cases in the spring of 2020 and a shortage of hospital beds, Whitmer issued an executive order on April 15 that required nursing homes with available capacity to create a dedicated unit to isolate residents with COVID-19 and accept COVID-19 patients discharged from hospitals. It also designated some nursing homes to serve as “regional hubs” to accept infected residents from facilities that couldn’t safely isolate them.

The requirement that non-hub facilities accept COVID-19 patients was never fully implemented, said Melissa Samuel, president of the Health Care Association of Michigan, a trade association that represents Michigan’s long-term health care providers and questioned the administration’s order.

Then in late May, Whitmer ordered all nursing homes to make a “reasonable effort” to establish a unit to isolate COVID-19 patients. Hospitals were required to keep patients until a spot in a nursing home, regional hub or other safe facility became available.

State officials were urged to consider other alternatives. Samuel initially suggested using vacant nursing homes. But she said it soon became clear that such facilities couldn’t be quickly staffed or equipped to become fully functional.

Another suggestion was field hospitals, which were also judged to be ill-suited to taking care of nursing home residents. Caring for the geriatric population “is very, very very different care from the general population,” Samuel said.

A task force charged with preparing nursing homes for a second wave of COVID-19 ultimately recommended staying with the regional hub approach, while beefing up staffing and infection-control standards. It received near unanimous support among state lawmakers.

Did placing COVID patients in nursing homes exacerbate the death toll?

From the start of the pandemic through Feb. 21, 2021, 8,003 Michigan residents were admitted or readmitted into nursing homes after being hospitalized and treated for COVID-19, according to data from the Centers for Medicare & Medicaid Services.

About 15,700 people have died in Michigan of COVID-19. Among them, 5,537 were residents of long-term care facilities, including 4,117 nursing home residents, according to the Michigan Department of Health and Human Services.

As nursing home deaths began to spike last spring, Whitmer faced heavy criticism over her orders and her administration’s lack of transparency about the impact on nursing home patients. The recent disclosure that New York state, which followed a similar policy, undercounted nursing home deaths have renewed those criticisms.

In a pair of tweets supporting GOP lawmakers’ call for an investigation, the Michigan Republican Party said that “Gov. Whitmer’s actions caused the deaths of thousands of Michigan seniors” and that the regional hub policy “exacerbated the death toll” from COVID-19.

We asked the party for evidence to back those specific claims, and it didn’t supply any. It pointed instead to data showing an increase in death rates in the fall of 2020 and said it’s seeking an explanation from the Whitmer administration.

MDHHS, for its part, couldn’t say whether any nursing home deaths were linked to the transfer of COVID-19 patients from hospitals. Instead, the health department cited a University of Michigan Center for Health and Research Transformation report with preliminary analysis that showed no evidence of transmission between COVID-19 patients admitted from hospitals to nursing home residents in hubs.

While the state’s top health official recently told state lawmakers that Michigan has done an “exemplary job” collecting and validating nursing home data throughout the pandemic, the CHRT team said a lack of reliable information prevented it from doing a more conclusive analysis of transmission between COVID-19 patients in nursing homes and other residents.

The researchers found that in the early days of the pandemic, the state health department and nursing homes were not prepared to gather, report, validate and analyze COVID-19 data.

Using the information they had, the researchers looked for statistical connections between transmission and case rates in regional hubs and didn’t find any. That doesn’t mean there wasn’t transmission, said Marianne Udow-Phillips, founding executive director of CHRT. Udow-Phillips said the team wasn’t able to complete a definitive analysis on transmissions in either hub or non-hub nursing homes because it didn’t have good enough information.

The team did find that the overall COVID-19 death rate was lower at the homes that were designated as regional hubs than at nursing homes that weren’t — 17% compared with 26%. During the period analyzed, non-hub facilities accepted more than twice as many recovering COVID-19 patients. There are over 400 nursing home facilities in Michigan. Only 21 served as regional hubs.

Another explanation for nursing home deaths

Samuel, from the nursing home trade group, said research pointed to other factors that may have contributed to nursing home deaths.

National studies show nursing home outbreaks were strongly associated with the COVID-19 infection rate in the surrounding community. In Michigan, too, the CHRT researchers identified a strong correlation between nursing home deaths and the prevalence of COVID-19 in the surrounding county as well as staff infection rates.

Nursing home staff exposure to the virus likely put residents at risk. “These are relatively low-paid staff, many of them have multiple jobs and many of them moonlight at other nursing homes,” said Udow-Phillips. “Most of the national data has supported this observation that it’s transmission from the community into the nursing homes and very much brought in by staff.”

Did Michigan undercount nursing home deaths?

GOP lawmakers calling for an investigation have raised concerns that the state has provided an inaccurate count of deaths among nursing home residents.

Samuel said she isn’t aware of issues with counting nursing home deaths.

But during the first few months of the pandemic, a lack of information on sick and dying residents muddied the picture.

It was difficult to confirm COVID-19 deaths, said Kevin Evans, executive director of the Martha T. Berry Medical Facility, a nursing home in the Detroit suburb of Mount Clemens. “We didn’t have enough test kits to determine how many deaths actually occurred based on COVID,” he said. 

The state’s earliest known COVID-19 death was a nursing home resident who was never tested. She died six days before the state reported its first COVID-19 death and weeks before the state began reporting cases in nursing homes, a Detroit Free Press investigation found.

On Apr. 21 — over a month after the state reported its first COVID-19 case — the state began requiring each long-term care facility to submit a daily report of the number of COVID-19 cases and deaths. The state released its first breakdown of COVID-19 deaths at each facility in early June.

“We had a less robust nursing home data system than most other states for COVID-19,” said CHRT’s Udow-Phillips. When the pandemic hit Michigan, a COVID-19 reporting system was essentially built on the fly, she said. Changing definitions made consistent reporting difficult for nursing homes, the CHRT researchers found. Information on nursing home COVID-19 admissions and cases was especially inconsistent during the early days of the pandemic, Udow-Phillips said.

But the mistake that led to the undercount in New York wasn’t repeated in Michigan, according to MDHHS.

In New York, nursing home residents who died in the hospital weren’t initially counted among nursing home deaths. In Michigan, they were counted among the dead if the facility was holding their place, said MDHHS spokeswoman Lynn Suftin.

Whether any nursing home resident deaths were connected to Whitmer’s decision to house COVID-19 patients in nursing facilities remains an unanswered question.

“One thing that I’m confident in is there’s nobody that can say with confidence that no deaths occurred because of that,” said Evans.

Dave Boucher contributed to this report.