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Assuring Nursing Home Quality: The History and Impact of Federal Standards in OBRA-87


In 1987, in response to a host of consumer complaints and state and federal reports criticizing nursing home quality, Congress passed Omnibus Budget Reconciliation Act of 1987, (OBRA-87). The sweeping reforms contained in OBRA-87, which were designed to ensure the well-being of frail elderly people, are now at stake as proposals to repeal or modify the Act are heard in Washington.

A timely analysis for The Commonwealth Fund, entitled Assuring Nursing Home Quality: The History and Impact of Federal Standards, by Catherine Hawes, director of the Program on Aging and Long-Term Care at the Research Triangle Institute, documents the difficulties encountered in enforcing state and federal nursing home standards before the enactment of OBRA-87.

Hawes writes that the pre-OBRA-87 standards were deficient, focusing on "paper compliance" with little regard for residents' health, safety, and rights. In addition, the compliance mechanisms were often ineffective or ignored.

The OBRA-87 reforms addressed the issue of actual care and ordered the "maximum possible functioning" for each resident, elevating patient rights and quality of life to equal standing with the quality of medical care. The reforms also instituted enforcement laws with swift mechanisms to deal with facilities not in compliance.

The reforms dictated by OBRA-87 have been successful. Use of psychotropic drugs and restraints has declined, hospitalization rates are down, and physical functioning of residents is up.

The evidence about these positive effects of OBRA-87 reforms, combined with the history of poor care and inadequate quality assurance before OBRA, suggests that a withdrawal or weakening of the new federal-state regulatory system could undermine the quality of nursing home care.

Cautioning that the dramatic improvements in the lives of the frail elderly and disabled would not have come about without the OBRA-87 reforms, Hawes warns that any reconsideration of current Medicaid law must recognize these impressive achievements.

Facts and Figures

Since the institution of OBRA-87 reforms:

  • There has been nearly a 50 percent reduction in the use of restraints, freeing 250,000 elderly patients each year.
  • There has been a significant increase in the involvement of families and residents in care plan meetings and decisions.
  • Psychotropic drug use has dropped by as much as a third.
  • Behavior management programs for wandering, aggression, or resisting care have increased by 27 percent.
  • The use of hearing aids has increased by 30 percent.
  • The use of toileting programs for incontinence has doubled.

The full report is not available at this time.

Publication Details



Catherine Hawes, Assuring Nursing Home Quality: The History and Impact of Federal Standards in OBRA-87 (Commonwealth Fund, Dec. 1996).