We hear a lot of rhetoric about the “New Hampshire advantage.” And yet to be elderly and frail in New Hampshire is a disadvantage compared with most other states. This disadvantage is amplified by COVID-19.

While some exult over our lack of a sales or income tax, there are human consequences. We also have New England’s worst gap between Medicaid payments and long-term care costs. Rather than raise taxes, the state can simply refuse to pay bills. This is not an option available to the average citizen, nor the average nursing home.

Thus the state with the second-oldest population, and perhaps the nation’s oldest nursing home population, struggles to staff the care needs of its most vulnerable.

Those struggles predated the pandemic. From June 2018 through May 2019, for example, the state saw a net loss of 567 licensed nursing assistants (LNAs) — the caregivers on the frontline in hospitals, nursing homes and many home care situations. From June 2019 through May 2020, the state suffered the net loss of another 709 LNAs.

Simply put, you cannot hire LNAs if there are no LNAs. And every time a nursing home suffers an outbreak, its LNAs — 92% of whom are women, often with kids to support on wages depressed by Medicaid reimbursement — rethink career options.

A state that recognizes the COVID-19 hazard in liquor stores with 10% wage increases discontinued a wage stipend program that recognized the hazards of caring for the state’s Medicaid clients in nursing homes, assisted living and home care. The result is a statewide staff exodus, and providers going further into the red to try to slow departures.

Thus, as this newspaper reported, an excellent family-owned nursing home in Sullivan County was, heartbreakingly, reduced to pleading for staff on Facebook (“2 die at Newport nursing home,” Nov. 11).

Providers here are not as fortunate as, say, those in Alabama, a state that raised its nursing home Medicaid rates by $20 per resident, per day and also gave $50 million in federal coronavirus relief act money to be used by nursing homes for staff bonuses and other costs. Or South Dakota, with a population roughly two-thirds that of New Hampshire, which allocated $115 million in coronavirus rescue funds to long-term care facilities.

Here in New Hampshire, all long-term care providers have had to compete for a promised $30 million in relief funds, of which around two-thirds has been distributed.

To be sure, there are many other pressing state needs, finite resources and tough decisions that might have tested the wisdom of King Solomon. But in recognizing that reality we also must recognize another: COVID-19 is on the march. It’s merciless. It’s nonpartisan. It plays no favorites, and is as apt to enter a “five-star” nursing home as any other. After all, they can’t even keep it out of the White House, with the nation’s most sophisticated testing regime.

Now, outbreaks once confined to southern New Hampshire are making their way north, with Berlin considering a mask ordinance. With people forced indoors, and holiday gatherings taking place despite warnings, community transmission will explode. And the human consequences will be devastating as the virus continues to infect, and kill, the elderly and those who care for them.

Whatever the source of relief, whether federal or state, without more help New Hampshire’s nursing homes — and many Medicaid-serving assisted living facilities — are in an untenable situation. As losses mount, four nursing homes are changing ownership. My association will be facilitating a bankruptcy seminar for facilities on the brink.

This is an existential crisis — will we rise up to meet it?

Brendan Williams is the president and CEO of the New Hampshire Health Care Association.