The Biden administration issued final rules setting minimum staffing levels and national waiting times for medical care in the nation’s 15,000 nursing homes certified for Medicare and Medicaid long-term care.
The new regulations “fulfill President Biden’s commitment to support family caregivers, boost compensation and job quality for care workers, expand and improve care options, and improve the safety and quality of care in federally-funded nursing homes,” the Centers for Medicare and Medicaid Services (CMS) stated in a press release announcing the final rules, on April 22.
Federal Standards, Secret Shoppers
The new rules bring a new level of federal micromanagement to the operation of nursing homes, which care for 1.2 million individuals daily, according to CMS figures.
Under the first-of-their-kind federal staffing requirements, all nursing homes must have a registered nurse (RN) on site 24 hours a day, seven days a week, and provide residents with a minimum total of 3.48 hours of nursing care per day, of which a little more than a half-hour must be from an RN. Facilities must conduct a “stronger annual facility assessment of resources and support,” including feedback from direct care workers, and develop a staffing plan to “maximize recruitment and retention.”
In addition, “[F]or the first time ever, states will be required to have national wait time appointment standards,” states the CMS press release. “States will enforce the wait time standards by introducing ‘secret shopper’ surveys, which can help verify compliance with appointment wait time rules and correct provider directory inaccuracies. States will also be required for the first time to disclose provider payment rates publicly.”
States will also be required to collect and report what percentage of Medicaid payments are spent on staff compensation and this data must be posted publicly.
‘We Don’t Have the Nurses’
The Biden administration’s call for increased staffing levels at nursing homes coincides with a growing shortage of nurses nationwide, according to a January 2024 report by the U.S. Chamber of Commerce.
“The United States is currently grappling with a nursing shortage that is causing a ripple effect of rising health care costs and lower quality of life across the country,” the Chamber’s report states. “By the year 2030, it is expected that 42 of the 50 states in the United States will experience shortages in nursing staff.”
The nationwide nursing shortage played a prominent role at a March 21 hearing before the House Ways and Means Committee, at which Health and Human Services Secretary Xavier Becerra was forced to defend the administration’s proposed nursing home rule.
“We don’t have the nurses,” Rep. Greg Murphy (R-NC), a practicing physician, told Becerra. “We have closed beds at my institution, at my medical center, because—guess what—we don’t have the nurses.”
Boosting Union Membership
The new rules are aimed at increasing union membership among nursing home employees, not improving quality, says Chris Jones, vice president for health care policy at the Texas-based Cicero Institute.
“The Biden administration is less interested in the well-being of nursing home residents and more interested in protecting a unionized workforce,” said Jones. “The administration focuses on inputs, not resident satisfaction.
“Not only will this drive up the cost of care and reduce the supply of nursing home beds, but residents want quality care, not ‘hours,’” said Jones. “Their family members want to know that their loved ones have needs met and are not needlessly having to have direct care staff checking a box because the government thinks they know better.”
‘This Is Unachievable’
CMS did not estimate the cost of the regulations to nursing homes, which will receive the same standard payments, says Jones.
“And finally, and most troubling, the administration did not even do the math to see that this is unachievable and will only drive the cost of health care up in skilled nursing, home- and community-based services, and general medical care,” said Jones.
There are even more cost-increasing regulations in store for nursing homes, says Jones.
“As another example of the ‘nanny state,’ CMS/CDC (Centers for Disease Control and Prevention) just promulgated new rules to enhance barrier protections in skilled nursing facilities,” said Jones. “It is clear this administration cannot do math or understand supply chains, much less the dignity of residents.”
‘Ties Providers in Regulatory Knots’
The CMS rules do nothing to improve long-term care, says Stephen Moses, president of the Center for Long-Term Care Reform and a visiting fellow at the Paragon Health Institute.
“CMS demands Ritz Carlton care at Motel Six rates,” said Moses. “Ever since OBRA ’87 (Omnibus Budget Reconciliation Act of 1987) required nursing homes to hire more staff, provide better training and improve quality…without increasing reimbursement, the federal government has tried to get something for nothing from long-term care providers.
“Medicaid dominates long-term care financing, does too little to ensure quality care, and ties providers in regulatory knots. These new rules pretend to provide long-term care, but they are more about virtue signaling for political advantage than about genuinely beneficial reform,” said Moses.
Bonner Russell Cohen, Ph.D. (bcohen@nationalcenter.org) is a senior fellow at the National Center for Public Policy Research.
