Many questions remain after an investigation by Pulitzer Prize-winning journalist Charlie LeDuff and the Mackinac Center concerning the total number of deaths from COVID-19 at nursing homes. A hearing on June 3 before the Michigan House of Representatives Oversight Committee featured comments from the Mackinac Center and Elizabeth Hertel, the director of the Michigan Department of Health and Human Services.

This is a complex issue, so it is important to have a clear description and understanding of the precise problem. The following explains the two aspects of our concern.

First, a word about terminology. Although commonly referred to just as “nursing homes,” there are three categories of facilities in Michigan that could be called nursing homes: 1) Skilled Nursing Homes, 2) Adult Foster Care, and 3) Homes for the Aged. Skilled Nursing Homes are regulated by the Center for Medicare and Medicaid Services and are under federal jurisdiction. Adult Foster Care and Homes for the Aged facilities are regulated by the Michigan Department of Licensing and Regulatory Affairs. All three are defined as “long-term care facilities” by MDHHS for COVID-19 reporting purposes.

Skilled Nursing Homes are subject to federal reporting requirements regarding COVID-19 cases and deaths. As Director Hertel stated during her testimony, these facilities simply report numbers to the federal government, and the state then uses that data to update its overall tally of deaths at long-term care facilities.

Adult Foster Care and Homes for the Aged are also required to report data, but only to MDHHS. Additionally, these facilities are only required to report death and case information if they were licensed by the state Department of Licensing and Regulatory Affairs to house 13 or more residents. Smaller facilities are not required to report, despite accounting for 76% of these facilities in Michigan. In other words, 3,480 smaller long-term care facilities, serving more than 22,000 elderly Michiganders, are not being tracked.

This is the first part of the problem. Because these facilities are not required to report COVID-19 deaths, there is no way to know how many people have died at these facilities from this disease. This is important information, especially valuable to inform policymakers regulating these facilities.

Despite this, death certificate records could be used to determine how many residents of these facilities died from COVID-19. The state regularly reviews these records and relies on them as a source for the state’s total tally of COVID-19 deaths. But MDHHS has not tried to link these death certificate records to long-term care facilities since last June, citing time and cost constraints. This is the second part of the problem.

The state is not counting any of the COVID-19 deaths it finds by reviewing death certificates to the tally for long-term care facilities. When the state had done this previously, it found that 44% of death certificates were for residents of long-term care facilities. Because of this, it is very likely that the state’s overall tally of deaths of residents of long-term care facilities is an undercount.

Creating more accurate data is simple. The health department could simply check if the address of the deceased listed on each death certificate matches an address of a licensed long-term care facility. If it does, and it was not already reported directly by a long-term care facility, the death would be added to the state’s total long-term care facility count. Again, the state used to conduct this type of analysis, so it is obviously possible in practice.

Of course, as Director Hertel pointed out in the committee hearing, this will not provide a full accounting. If, for instance, the address on a death certificate is listed as the deceased’s residential home, rather than their long-term care facility, it would not get classified as a death at a long-term care facility. But that’s not a reason not to do it. The resulting data would still be more accurate than the state’s current figures.

In sum, we know that the state’s total count of COVID-19 deaths at long-term care facilities does not include data from smaller facilities, nor does it include data from conducting a review of death certificates. The result of this is that the state’s tally of deaths at long-term care facilities is not thorough and an undercount. How much of an undercount is not easy to estimate, but there’s no reason why the state shouldn’t be doing everything it can to produce a more precise figure.

Permission to reprint this blog post in whole or in part is hereby granted, provided that the author (or authors) and the Mackinac Center for Public Policy are properly cited.