Republicans are expected to rescind the Biden administration’s contentious nursing home staffing rule before it is set to take effect.
The move would come as a relief for the nursing home industry, which has argued the mandate doesn’t appropriately address current workforce challenges. But consumer advocates and public health experts who have fought to protect the rule fear repealing it will harm residents and long-term care facility workers alike.
More than 200,000 nursing home and long-term care residents died during the first two years of the COVID-19 pandemic, with the spread of the virus and resulting deaths linked to staffing shortages.
In response, the Biden administration proposed three reforms to nursing homes, including setting a national minimum staffing requirement.
As part of the rule establishing that requirement, which was finalized earlier this year, nursing homes would be required to provide every resident with at least 3.48 hours of nursing care a day, including at least 0.55 hours of care from a registered nurse and 2.45 hours of care from a nurse aide.
It also would require nursing homes to have a registered nurse on site 24 hours a day, seven days a week to ensure that critical care can be given to residents at any time.
The rule has faced bipartisan opposition, with Republicans pushing particularly hard against the staffing mandate.
Lawmakers in both the House and Senate introduced joint resolutions under the Congressional Review Act (CRA) to overturn the rule in the months after it was finalized.
“Severe workforce and nursing shortages have already hampered access to care. The Biden administration’s rule would only make it worse,” Sen. Bill Cassidy (R-La.), ranking member of the Senate Committee on Health, Education, Labor and Pensions, said in statement after co-sponsoring the Senate measure introduced by Sens. James Lankford (R-Okla.) and Joe Manchin (I-W.Va.). “We are pushing to ensure seniors can rest easy knowing they can access quality care when they need it.”
Neither of the resolutions has passed, and the rule is currently set to take full effect for urban facilities in 2027 and for rural nursing homes in 2029.
GOP lawmakers proposed fully repealing the rule as part of a preliminary offer for health care policies to be added to the continuing resolution Congress is working to pass by Dec. 20 to avert a government shutdown.
And there are multiple ways it could be blocked from being implemented or undone entirely under the incoming Trump administration.
Lawmakers in the House and Senate, both of which will soon be controlled by narrow GOP majorities, could pass legislation like the Midnight Rules Relief Act, which would amend the CRA to allow Congress to overturn federal regulations enacted during the final year of the current administration instead of the current 60-day look-back period, according to Leading Age, a nursing home industry group.
Congressional lawmakers could also use the budget and appropriation process to stop the implementation of the rule.
On top of this, the Trump administration could issue a new rule to roll the current one back or eliminate it, according to health policy nonprofit KFF.
“This would have to go through the rulemaking process but could ultimately undo the provisions in the rule,” said Priya Chidambaram, senior policy manager on Medicaid and the uninsured at KFF.
Beyond the incoming Republican trifecta, the court battles currently playing out over the rule also provide a potential avenue for it to be overturned.
Its defeat would mark a victory for the nursing home industry, which has urged Republican lawmakers — along with some Democrats — to scrap the rule, arguing that it sets an impossible, and pricey, standard for facilities to meet that will ultimately worsen care for residents and cause closures.
Instead, nursing home industry groups like the American Health Care Association and National Center for Assisted Living (ACHA/NCAL) have called for “targeted investments” to increase the long-term care workforce.
One proposed strategy to help attract more caregivers to the profession is to offer financial assistance for current or future caregivers as well as training and educational opportunities, according to the group’s website.
“Nursing homes will struggle to find qualified caregivers and be forced to limit admissions, downsize, or close altogether,” a spokesperson for the AHCA/NCAL wrote in an email to The Hill.
The organization was one of two industry groups that filed a lawsuit earlier this year in an attempt to block the rule.
Less than 20 percent of nursing facilities in the country currently meet all three of the minimum staffing requirements in the rule, according to an analysis from KFF. And most of the facilities that are not meeting those requirements are for-profit nursing homes or long-term care facilities.
According to the analysis, 11 percent of for-profit facilities can meet the staffing minimums, while 41 percent of nonprofits and 39 percent of government facilities can.
The AHCA/NCAL estimates that the nursing home industry would need to hire roughly 100,000 more nurses and nursing aides to ensure that every facility meets all three of the rule’s requirements. That bump in staffing would cost $6.5 billion a year, the organization said.
The federal government, meanwhile, estimates the cost of implementing the final rule would be $43 billion over 10 years.
But however costly or “illogical” opponents of the rule believe it to be, labor unions, consumer advocates and public health experts have contended it would ultimately help improve the health and safety of nursing home residents and staff.
“We have minimum staffing standards for doggy day cares, we have minimum staffing standards for child care centers,” said Sam Brooks, director of public policy at the National Consumer Voice for Quality Long-Term Care. “It’s absurd to think that this is some burden that is going to undo the industry.”
Brooks told The Hill that the rule is designed to raise the standard of care at the worst-performing nursing facilities in the country and that it is not a “one-size-fits-all” mandate.
One 2024 study found that fewer nursing home residents are hospitalized or visit emergency rooms at facilities with more registered nurses. Another 2024 study from the University of California, San Francisco shows that nursing homes with higher numbers of certified nursing assistants improve the quality of care residents receive.
Sherry Culp, the long-term care ombudsman at Kentucky’s Cabinet for Health and Family Services, recalls how the importance of staffing at nursing and long-term care facilities was repeatedly underlined at 20 nursing home resident forums she and her colleagues hosted across the state.
“Staffing was the thing that came up at every forum, and the negative impacts of being short-staffed,” said Culp. She added that she recently received a report of how a rapidly declining nursing home resident was left grossly unattended to due to understaffing.
The resident’s decline was discovered after a family member visited them and found them unable to speak with multiple trays of untouched food around their bed and their shoes filled with urine, she said.
“If there were sufficient staff, would someone not be coming in to check and see if this person was able to eat … or to come in to see if that resident needed assistance to go to the toilet or needed to be changed?”
Experts, advocates and unions are fighting to keep the rule from being overturned. In a joint letter to congressional leadership last week, they urged lawmakers to oppose any legislation or end-of-year deal that “derails or postpones” it.
“Industry opposition makes little sense when many facilities already meet or exceed specific components of the staffing rule and when the rule’s total ratios are less than current national averages,” the letter reads.
“There is virtually universal agreement that facilities should employ registered nurses around the clock. Fundamentally, it is a rule designed to address the poorest-performing homes in the country.”
