WASHINGTON — A provision of the Republican tax and spending package now before the Senate would pause a looming requirement for nursing homes to provide nearly three-and-a-half hours of direct nursing care to each patient each day. This includes tasks such as wound care, and assistance with dressing, eating and other daily activities. The rule is supposed to take effect next spring.
A court ruling in April blocked the minimum staffing requirement for now, but the provision in the Republican bill would cancel it.
“It's codifying that it's going away, as opposed to just relying on the court ruling,” said Jennifer Johs-Artisensi, a health care administration professor at the University of Wisconsin-Eau Claire. “There were a lot of concerns that, even though it was well intended, that it could have some effects of places closing because they couldn't find the staff to meet the minimums, and then reducing access to care for people who obviously still need care.”
Groups representing long-term care providers support blocking the staffing requirement.
“Unfunded mandates on providers are not going to help improve quality of care,” said Lisa Davidson, president and CEO of LeadingAge Wisconsin, a long-term care provider association. “Our members already do a very good job.”
“They can risk being in violation of the regulation, or they can reduce the number of beds that they staff. That's a lose-lose,” said Rick Abrams, CEO of Wisconsin Health Care Association & Wisconsin Center for Assisted Living, a nonprofit representing the state’s long-term care providers.
Abrams said nursing facilities already have a duty to provide adequate care with sufficient staffing.
“If you have an ownership that consciously under staffs their facility, they should be out of the sector. They should not be allowed to care for the most vulnerable people in our society. And I would dare say that that is the vast, vast, vast exception,” Abrams said.
In Wisconsin, nursing homes provide an average of 4.05 hours of nursing care to patients per day, according to the Long Term Care Community Coalition, a nonprofit that advocates for people in nursing homes.
In a statement to Spectrum News 1, the organization's executive director, Richard Mollot, said it would be a disservice to American families to cancel the minimum staffing requirement, calling it “modest” already and saying it’s “well below the level needed to provide decent care for vulnerable residents.”
“Thus, it serves two important purposes,” Mollot said. “1. To clean up the worst of the worst providers, who are profiteering off of resident neglect, and 2. To improve the value of the care that Americans are paying for through the Medicare and Medicaid systems. We pay for good care but, far too often, we don’t get it.”
But Dr. Frances M. Hawes, another health care administration professor at UW-Eau Claire, told Spectrum News 1 canceling the federal staffing mandate is a step in the right direction.
“The rule imposed a one-size-fits-all standard that many communities simply cannot meet due to severe workforce shortages and a lack of available licensed staff,” he said. “It would have diverted limited resources away from real solutions to build and retain the workforce.”
The Congressional Budget Office estimated eliminating the rule will save the federal government more than $20 billion over the next decade.
“There is a lot of administrative cost that goes into implementing this rule,” Davidson said. “We think that there are resources out there that are going to be much better invested and targeted for those types of initiatives, rather than imposing new regulations that would be very difficult to implement. We can't just hire people out of thin air. There's a lot of steps that go into growing people, and especially as you talk about nurses, registered nurses, there is a number of years of education and experience that go into that degree, and so we cannot just grow those people overnight."
Another provision of the legislation, which would enact President Donald Trump’s domestic agenda, would make changes to Medicaid, the federally program that helps low-income people pay for health care. The Congressional Budget Office said Wednesday that if the legislation is enacted, 10.9 million fewer people would have health care.
“Looking at different elements of Medicaid, such as the work requirements, and having that be applicable to people who are going to be very near to what we see today as a traditional retirement age and Medicare eligibility, that could end up being problematic,” Davidson said.
Hawes said the so-called Big Beautiful Bill raises “serious concerns.”
“Rather than addressing the root causes of the staffing crisis,” he said, “it adds new burdens while failing to fix what matters most. Medicaid reimbursement rates remain too low to cover the actual cost of care, making it harder for providers to hire, retain, and fairly compensate staff. Clinicians and frontline caregivers must be adequately supported to ensure patients receive consistent, quality care. At the same time, adding Medicaid work requirements threatens coverage for vulnerable populations, particularly middle aged women who are already balancing low wage jobs and unpaid caregiving. Medicaid is the backbone of long-term care in the U.S., particularly for nursing homes. Undermining that system without meaningful investment in the care workforce could destabilize a sector already under immense strain.”
A strain that Mallot argued is the sector's own fault.
"The nursing home industry and its multi-million dollar lobbyists have been arguing for decades that they cannot provide better staffing because there is a staffing 'crisis,'" he said. "In fact, nursing homes average over 50% turnover. The crisis isn’t in finding nursing staff but, rather, in retaining them. The industry provides poor compensation and very dangerous and demeaning working conditions. To the extent that a crisis exists, it is of their own making. Putting public resources into addressing it will only delay necessary reforms."
Johs-Artisensi said nursing homes were already working to build up staff to meet the federal requirement.
“I will say, there's many, many care communities that staff well above the minimum,” she said. “A lot that's targeting at a minimum level is really designed to kind of bring those at the bottom up… And to be fair, I think a lot of those care communities would also like to bring those staffing levels up, but we are also operating in an economy and in a health care system, or a long-term care system, where the majority of nursing homes are reliant on Medicaid reimbursement. [It] pays the bill for most of their clients. Probably around 70% of people in nursing homes have Medicaid as their primary payer source, and so governments set the bill for how much they will pay. So you've got a lot of states that are operating on limited revenues, because they have high Medicaid populations, and Medicaid budgets are always struggling for cash, it seems.”
Groups representing long-term care providers said the government could address a nursing home staffing shortage by incentivizing people to work in health care, and streamlining the immigration process to more easily allow foreign nurses into the country.
“We have a very difficult time getting people into long-term care careers, whether that's in assisted living or if that's in nursing homes,” Davidson said. “We need to make sure that, especially when we talk about Medicaid as a payer, we need to stay competitive with the private sector and with private pay. And if we are not able to do that, then we are going to be losing good people to other careers.”
Nursing homes are fined when they aren’t in compliance with state and federal regulations. Davidson and Abrams said the money that's collected that way could be reinvested to improve the quality of care at struggling nursing homes.
"We want to make sure that staff have all the support that they need, that the patients have access to the latest and greatest in terms of being connected to technology where appropriate, and we just want to make sure that everybody has the same quality of life, regardless of who their payer source is for their care," Davidson said.
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