For those living in nursing homes, the validity of nursing staff is a matter of life and death. So the Biden administration issued federal rules last year, setting minimum staffing standards. Our estimates are that they save 13,000 lives a year. However, these rules are currently under attack.
The Trump White House should protect them rather than reverse or weaken them as part of a greater effort to repeat regulations across the government.
Rules finalised in April last year represent some of the most important reforms in nursing home care in decades. Additionally, the rules are currently at serious risk, as more staffing costs most nursing facilities to operate. But that becomes a core mission of the industry: money that is well spent on caring for the residents.
President Trump's choice to lead the Department of Health and Human Services, Robert F. Kennedy Jr. told lawmakers at a confirmation hearing last week that the rules were “well intended,” but would be “a disaster,” especially for rural nursing homes. Twenty Republican state attorney generals went to federal court to cancel the rules. The same is true of the nursing home industry group.
This corresponds to an attack that is some of our most vulnerable Americans. This is about 1.3 million people living in nursing homes where staff shortages and sales are a major problem. The rules, which are being implemented in stages over the next few years, require registered nurses to stay 24 hours a day, seven days a week, and require a minimum of 3.48 hours of nursing care per day, primarily from nursing aides.
That may sound a lot, but most nursing homes in the US do not meet these basic minimums. According to the analysis, 83% of nursing home staffing levels in the first half of 2023 are below the new requirements for the first half of 2023.
As researchers who have been studying nursing homes for decades, we know how important nursing home staff are and why efforts to roll back new minimum staffing rules pose such a threat to residents and their families who rely on these staff.
This will be especially true in the coming years. The fastest growing age group in the United States is already over 65 years old. One in six Americans are classified into that age group, making up 17% of the population. That percentage is expected to rise to 22% by 2040.
When providing advice on choosing a facility for your loved one, we cited the number of nurses and their aides as one of the most important factors. In households with more nurses and aides, residents experience less bed sources and urinary tract infections. They are more active and live longer. However, U.S. nursing homes suffer from a major staffing shortage.
What impact will the new regulations have? We reviewed estimates of the relationship between total nurse staffing time and mortality rates from published studies. All we found was a surprise to us. By achieving minimum staffing levels, it saves approximately 13,000 lives per year in US nursing homes. And it does not include infections or other serious medical issues that are prevented.
It is true that it has been difficult to hire and maintain staff in nursing homes, especially since the pandemic. However, nursing homes outside the rural areas must meet new standards until 2026, and rural facilities are spending more time. Facilities are eligible for exemptions if they are unable to reasonably meet the criteria, and the federal government offers $705 million programs, including scholarships and tuition reimbursements, to train the next generation of caregivers.
The Biden administration estimated that the new rules would cost around $4.3 billion a year. According to one major industry group, that number is $6.5 billion a year.
The industry is unclear how nursing homes will spend their funds. Although reported profit margins are weak, facilities regularly operate at revenue-raising prices, effectively collecting revenue from related companies that hide profits. A recent analysis by the National Bureau of Economic Research found that more than two-thirds of profits are thus hidden. Artificially low benefits should not be used as justifications to eliminate important criteria. But that seems to be what the industry wants.
Interestingly, a 2023 analysis of the impact of the rules by KFF, previously the Kaiser Family Foundation, found that 90% of for-profit nursing facilities would need to hire more registered nurses or nurse aides to comply with the proposed staffing, compared to 60% of government and non-profit facilities.
Many nursing homes may require minimal changes to comply. Currently, around 20% of nursing homes meet these criteria, but the analysis shows that an additional 14% are only out of compliance, or a few months of the year. The rules also include difficult exemptions for facilities that cannot truly meet the requirements, minimizing the burden on the most vulnerable agencies.
The truth is that nursing homes can meet these criteria. The for-profit nursing home industry bypasses hundreds of millions of profits to executives and shareholders, the money that could be redirected to hire more nurses. California has had a net increase in the number of nursing homes due to the presence of minimum staffing requirements for over 20 years, while also providing low mortality, improved nurse retention and quality care.
Federal minimum staffing requirements provide better care and opportunities to extend lives for older Americans. We shouldn't let it run away.
