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Staffing mandates would hurt Pa. nursing home care

There has been an undeniable nursing home workforce crisis in recent years. While many have moved on from the pandemic, the stress and anxiety continue in nursing homes as employees work hard to protect those most vulnerable to COVID-19. Though well-intentioned, a proposed federal staffing requirement by the Centers for Medicare and Medicaid Services (CMS) for nursing home providers will have the opposite effect, leading to a reduction of beds available to Pennsylvania seniors.

The issue: Government has been underfunding Medicaid needed to care for seniors at historic levels. In Pennsylvania, Medicaid had been underfunded by $1.2 billion according to a 2022 study, and the number of skilled nursing beds pulled offline grew fourfold from 2019 to 2021.

Before staffing mandates can be reasonably considered, our federal government must recognize providers are in crisis and residents’ access to care is at risk, due in large part to historic underfunding and a workforce crisis that pre-dates the pandemic and worsened after it began. Last year, Pennsylvania took an important step forward when the Wolf administration and General Assembly provided a 17.5% rate increase in direct aid to nursing homes—the first across-the-board Medicaid funding increase in nearly a decade. But that was only a first step. Even with this rate increase, a sizable gap remains.

Not-for-profit facilities and those that rely heavily on state Medicaid payments do in fact require additional funding to meet these challenges and offset the increased costs and inflation that have arisen out of the pandemic. A minimum staffing standard, which fails to take into account the individual nuances of each state and community, only further exacerbates these financial challenges and will likely lead to additional closures and a reduction of beds available to serve our nation’s older adult population. Largely dependent upon publicly set Medicaid rates, most nursing facilities cannot simply raise wages to attract more staff.

A January 2023 report from the Medicaid and CHIP Payment and Access Commission ( showed that almost half of states’ average Medicaid base rates across the country were lower than 86% of nursing home costs in 2019. Those costs have only further inflated due to the impact of the pandemic. Simply put, Medicaid reimbursement dollars have been less than adequate to keep up with the rising costs of operating nursing homes and other care communities.

Proposed federal staffing mandates also ignore the realities of available workforce. LeadingAge members have reported that, on average, 20% of their direct care and nursing job postings draw no applicants. This problem is only worsened by predatory staffing agencies taking advantage of nursing facilities who are desperate for staff.

Nursing facilities’ commitment to maintaining (or even increasing) staffing ratios throughout the pandemic, despite decreasing staff availability and increased costs, shows their dedication to and understanding of the need for appropriate staff levels to safely meet the needs of the residents in their building. Rather than operate at unsafe levels, they have continued to fulfill that intrinsic commitment, even at the cost of taking beds offline when necessary or in some cases closing the facility.

It's also important to note that Pennsylvania has already successfully negotiated reasonable staffing requirements tied to a necessary funding increase. Last year, LeadingAge PA worked with the Wolf administration, General Assembly and other stakeholders to negotiate relatively reasonable staffing standards tied to a long overdue increase in funding for Medicaid-certified nursing facilities, along with a mutual acknowledgement and agreement of the need for additional investment moving forward to offset historic underfunding and rising costs.

While there remains work to be done in many other areas to help support bolstering the long-term care workforce (funding alone will not alleviate the workforce crisis!), this was a crucial first step that allowed the state and providers to come. This allowed us all to work toward our shared goal of improving quality and promoting access to care. A federal mandate would not only undo this important work, but also would place a roadblock in front of other state governments, providers and stakeholders to do the same.

We are experiencing the most difficult and critical time in my 38 years in this important field. We have seen over 300 nursing communities close in the U.S. since the start of the pandemic. We need to establish partnerships with state and federal agencies to create solutions without increasing undue regulatory burden. We share a mutual concern that seniors deserve better care and are ready to work together to alleviate the current crisis.

Given the grossly underfunded Medicaid program, enforcing a federal staffing standard will lead to increased costs and a reduction in bed availability from already underfunded organizations. If this happens, quality will suffer and access to care will erode particularly for low-income seniors. Pennsylvania is proof that when industry and government come together, states can improve quality and access to care in sustainable ways.

Jim Pieffer is President and CEO of Presbyterian SeniorCare Network, which serves more than 6,500 older adults through in-home and community-based programs across Western Pennsylvania.

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