Staffing Mandates Boost Nurse Levels Without Closures

PHILADELPHIA, PA — Mandatory nurse staffing requirements at nursing homes successfully increased staff levels without harming facility finances or causing closures, according to a comprehensive 14-year study published March 5, 2026 in Health Affairs.

The research examined nearly 7,000 nursing homes across 22 states between 2010 and 2023, comparing facilities in 11 states that implemented or updated staffing mandates against those in 11 states without such requirements. According to the study by researchers Rachel M. Werner, Xinwei Chen, Norma B. Coe, and Andrew R. Olenski, facilities subject to staffing mandates saw nurse staffing increase by 0.18 hours per resident day—approximately 5% overall and 8% before the COVID-19 pandemic—without experiencing detectable negative financial impacts.

The findings directly contradict arguments made by the nursing home industry when opposing the federal nurse staffing rule promulgated in 2024, which the current Administration cited when repealing that rule through an interim final rule in 2026. Industry representatives had claimed that staffing mandates would create unsustainable financial burdens and force facility closures.

Study Findings Challenge Industry Arguments

The research analyzed 4,551 nursing homes in states with staffing mandates and 2,298 facilities in states without such requirements. According to the published results, certified nurse aide staffing increased by 0.13 hours per resident day (5.7%) while licensed practical nurse staffing rose by 0.06 hours per resident day (7.5%) in states with mandates.

Despite these staffing increases, researchers found no statistically significant changes in the probability of facilities reporting positive profit margins, according to the study. While direct care expenses increased by $273,000, facilities simultaneously experienced a $546,000 increase in net patient revenues. The research also found no meaningful change in nursing home closure rates.

Researchers used data from the Healthcare Cost Report Information System (HCRIS), which the study describes as the only national source of information on nursing home financial health, though the authors acknowledged this data is self-reported and unaudited. The study also cited what researchers called a "significant lack of transparency around nursing home costs and finances" and "substantial hidden profits from related party transactions."

Industry Response and Historical Context

Industry trade groups quickly criticized the research findings. Rachel Reeves of the American Health Care Association described staffing mandates as "an antiquated approach in today's healthcare space," according to reporting in McKnight's Long-Term Care News.

Jodi Eyigor of LeadingAge commented that the federal staffing rule's requirement for 24-hour registered nurse coverage was "rigid" given nationwide RN shortages, as reported by McKnight's. However, this position contradicts LeadingAge's own 2022 "Care for Our Seniors Act" proposal, which the organization developed jointly with AHCA. That document explicitly called for "a new federal requirement that each nursing home have a RN on-staff 24 hours a day," citing research showing "a positive association between RN hours and overall quality."

The study identified several factors that may have contributed to increased facility revenues during the study period, including higher Medicaid reimbursement rates, increased Medicare admissions, implementation of the Patient Driven Payment Model for Medicare Part A reimbursement, and COVID-19 relief funding.

Staffing Challenges and Recommendations

Researchers noted that previous studies have documented nursing homes responding to staffing mandates by shifting toward lower-skill workers and reducing non-direct care staff in areas such as housekeeping, food services, and activities programming. The Center for Medicare Advocacy has encouraged states considering staffing legislation to draft requirements carefully to prevent such shifts and cutbacks.

To address ongoing workforce challenges, researchers recommended strategies including higher wages and benefits for nursing staff, support for unionization efforts, and easing immigration restrictions to expand the available workforce pool.

"We found that state nursing home staffing mandates were effective at increasing staffing levels but had no detectable effect on nursing home finances and did not lead to nursing home closures," the researchers concluded in their published findings. "These results suggest that more widespread use of staffing mandates could benefit residents without harming nursing homes."

The research was published by Penn LDI (Leonard Davis Institute of Health Economics) and comes at a critical time as policymakers debate the future of federal nursing home staffing requirements.

Resources for Families

Families with concerns about nursing home staffing levels can contact their state's Long-Term Care Ombudsman program, which provides free advocacy services for nursing home residents. The National Long-Term Care Ombudsman Resource Center can be reached at 1-800-677-1116 or through their website at ltcombudsman.org.

Residents and family members can also file complaints directly with their state health department or through Medicare's online complaint system. Federal regulations require nursing homes to maintain sufficient staffing to meet residents' needs, though specific minimum requirements vary by state.