PHILADELPHIA, PENNSYLVANIA — A comprehensive study examining nearly 6,900 nursing homes across 22 states over a 14-year period has found that minimum staffing requirements increased care levels without triggering facility closures or measurable financial harm, according to research published in Health Affairs.
The study, conducted by researchers from the University of Pennsylvania's Leonard Davis Institute of Health Economics, analyzed data from 2010 through 2023 to evaluate the impact of state-level staffing mandates on nursing home operations and finances. Lead author Rachel M. Werner, MD, PhD, Executive Director of LDI, stated that the findings provide compelling evidence that elevated staffing levels do not cause financial damage to nursing facilities.
According to the research, facilities subject to staffing mandates increased direct care staff by approximately 0.18 hours per resident day, representing a 5% overall increase and an 8% increase during the pre-COVID period. The study compared 4,551 nursing homes in 11 states with staffing requirements against 2,298 facilities in 11 states without such mandates. States with new or strengthened mandates during the study period included Arizona, New York, Rhode Island, Washington, Arkansas, California, Connecticut, Illinois, Massachusetts, Oregon, and Pennsylvania.
Financial analysis revealed that while direct care expenses rose by approximately $273,000 per facility annually, net patient revenues increased by roughly $546,000—effectively doubling the added labor costs, according to the Medicare Advocacy Center's analysis of the study. Researchers found no statistically significant change in facility profitability or closure rates associated with the staffing requirements.
The workforce gains were distributed across certified nurse aides, who saw a 0.13 hours per resident day increase representing a 7.5% gain, and licensed practical nurses, who experienced a 0.06 hours per resident day increase, also representing a 7.5% gain, as reported by the Center for Medicare Advocacy.
Dr. Werner indicated that the findings suggest a federal minimum staffing mandate or expanded state-level requirements would likely not harm nursing homes financially.
Industry Response and Criticism
The research drew sharp criticism from major industry organizations representing nursing home providers. Rachel Reeves, Senior Vice President of the American Health Care Association and National Center for Assisted Living, characterized staffing mandates as an outdated approach and argued that the heterogeneous nature of state policies obscured the study's conclusions, as reported by McKnight's Long-Term Care News.
LeadingAge Vice President Jodi Eyigor contended the study omits significant tradeoffs that facilities made to comply with staffing requirements, according to multiple reports. These alleged unmeasured consequences include reduced Medicaid admissions, cuts to dietary and housekeeping staff, and diminished quality-of-life programming for residents.
The criticism drew attention to an apparent contradiction in LeadingAge's position, as the organization's own 2022 policy proposal explicitly supported 24-hour registered nurse coverage requirements, according to McKnight's reporting.
Policy Context
The study arrives at a pivotal moment for federal nursing home policy. In 2026, the Biden administration issued an interim final rule rescinding a federal staffing requirement that had been previously established. The administration cited industry arguments about financial viability and workforce availability as factors in the decision.
The Center for Medicare Advocacy noted that the Penn research directly contradicts the industry arguments used to justify the federal rollback. The organization recommended several complementary measures to support adequate staffing, including higher wages for nursing home workers, expanded unionization opportunities, and relaxed immigration restrictions for healthcare workers.
Federal regulations require nursing homes participating in Medicare and Medicaid to provide sufficient staffing to meet residents' needs, though specific numeric requirements have varied over time. The debate over appropriate staffing levels has intensified as the industry faces ongoing workforce challenges and financial pressures, particularly in the aftermath of the COVID-19 pandemic.
State-level mandates typically specify minimum hours of direct care per resident per day, often broken down by staff category including registered nurses, licensed practical nurses, and certified nurse aides. The requirements vary significantly by state, with some mandates focusing on total nursing hours while others specify minimum levels for particular staff categories.
Resources for Families
Families with concerns about staffing levels or care quality at nursing homes can contact the National Long-Term Care Ombudsman Resource Center at 1-800-677-1116. The ombudsman program provides free advocacy services for nursing home residents and their families.
Additional information about nursing home quality ratings, inspection reports, and staffing data is available through Medicare's Nursing Home Compare website. Families can also file complaints directly with their state's health department or survey agency responsible for nursing home oversight.
For concerns about potential violations of federal care standards, families may contact their state's long-term care ombudsman program through the national hotline or visit ltcombudsman.org for resources and guidance on reporting procedures.
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