Fewer Nurses, More Harm in America’s Nursing Homes
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In December 2025, the Trump Administration repealed a rule issued by the Centers for Medicare & Medicaid Services, Department of Health and Human Services, that set a minimum standard requiring clinical staff to be present in nursing homes and other long-term care facilities. Advocates and elder care policy experts had been fighting for the legislation since 1987, but opponents, chiefly long-term care facilities, claim the move would cost too much and cause nursing homes to close.
We spoke with long-term care policy experts, physicians, nurses, and other industry experts to assess the veracity of such claims and the impact of this ruling on residents and care workers who serve them.
Biden-Era Safe Staffing Requirement for Nursing Homes
The Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting rule received final approval in June of 2024 and was set to be implemented in 2026.
This rule required the following minimum staffing standards in nursing homes:
- One registered nurse (RN) onsite 24/7
- Minimum of 3.48 total nurse staffing hours per resident per day
- 0.55 staffing hours per resident per day for direct care provided by registered nurses
- 2.45 nurse aide hours per resident day
The Long Fight for Elder Care
Anne Montgomery, MS, is an experienced policy analyst and health systems researcher specializing in long-term care (LTC) and support systems for older adults. She has served as a senior advisor to Congress for a decade, developing legislative policy for the Senate Special Committee on Aging and the House Ways & Means Committee. She currently works as a consultant with the National Committee to Preserve Social Security and Medicare, AgingIN, the Live Oak Project, Gray Panthers NYC, and more.
According to Montgomery, the 2024 rule was the culmination of a long-fought battle waged by advocates and healthcare policy experts that began with the 1987 Nursing Home Reform Act, which set federal quality standards for nursing homes for the first time.
While the bill certainly was an improvement, according to many care experts, it did not go far enough and left many requirements and their implementation unclear.
This vague language created a loophole for the LTC industry to interpret as they wish, and Montgomery says that was a mistake: “The 1987 bill required eight hours of RN care to be provided to residents each day, with no minimum requirements for other care staff like LPNs and CNAs. Instead, it used vague language and instructed that other direct care roles be staffed ‘sufficiently.’”
According to her, the nursing home industry took that flexibility and ran with it, often staffing nursing homes inadequately, which led to poor care and outcomes for elders.
For years, Montgomery fiercely advocated for stronger staffing requirements in her role as a senior advisor to the Senate Special Committee on Aging. In 2010, when the Obama administration passed its landmark Affordable Care Act, it included additional positive changes for the industry, but not the specific staffing minimums that researchers believed were crucial to achieving positive clinical outcomes and keeping residents safe.
Finally, in 2024, the Biden administration took up the mantle and imposed firm staffing requirements, so nursing homes could no longer skirt their responsibilities.
Yet the nursing home industry fought these changes vigorously and eventually succeeded in having the ruling repealed in December 2025. Healthcare policy experts and clinicians are distraught at this puzzling reversal. One such dissenting voice is Peter Kowey, MD, a cardiologist, professor, researcher, and author of Failure to Treat: How a Broken Healthcare System Puts Patients and Practitioners at Risk.
Dr. Kowey says:
“This rule was put forth to protect the elderly by making sure there is adequate staffing in these facilities, particularly nurses. Nurses who care and have a deep level of knowledge are necessary, given how increasingly complex and sick nursing home patients are. Covid-19 made it very clear how easy it is to overwhelm nursing home staff when many residents get sick at once. But incredibly, despite the million-plus deaths we witnessed, lobbyists from the LTC industry were able to convince this administration that those crucial staffing requirements enacted weren’t necessary. And it’s a disgrace.”
So if healthcare providers, policy experts, and elder care advocates all supported these staffing requirements, who opposed them, and why?
Safe Staffing: A Growing Public Crisis
Safe staffing continues to top the list of concerns that nurses identify across the country, year after year. From New York City to California, nurses and other healthcare workers are striking in record numbers, and their top demand is related to safe staffing. That’s because inadequate staffing is the single biggest contributor to burnout, moral distress, and workplace violence that drives nurses from the profession in droves.
There are 30 years of research showing the importance of having sufficiently skilled, experienced nurses on staff to provide direct patient care. Each unit is unique, but nurse researchers have calculated a minimum staffing ratio for each hospital department to ensure patients safety. Every patient a nurse must care for past that minimum increases the likelihood of their patients dying by 7 percent.
“Nurses are striking all over the country right now. And if you speak to any nurse on the picket line, they will tell you what they’re fighting for above all else: safe staffing. And we as doctors and as the institution of healthcare overall have let them down by not supporting them in that fight,” says Dr. Kowey.
Despite the overwhelming evidence and demand from bedside nurses, virtually nothing has been done to address this all-important issue. Why?
Those who oppose mandated staff ratios argue that they oversimplify a complex equation and risk causing unintended consequences. Robert Wingo, BSN, RN is an experienced nurse leader and consultant who teaches nursing managers how to maximize their budgets to fight the staffing crisis.
“Ratios ignore the critical role of unlicensed support staff (e.g., nursing assistants) in care delivery and do not account for innovative care delivery models such as virtual nursing. They could also exacerbate inequities in healthcare markets by disproportionately straining less affluent hospitals,” Wingo says.
The California Case Study
Luckily, we have the perfect case study to evaluate these claims, since California has already done so. After a decade of ceaseless grassroots nurse advocacy, California made minimum, specific numerical staffing ratios the law of the land in 2004. Since then, researchers have analyzed the effects this change had on patient outcomes, nurse retention, and quality metrics–all in the context of the 2008 financial crisis and the recovery period afterward. So what did they find?
According to a landmark study conducted by famed nursing researcher and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing, Linda Aiken, PhD, RN: “Hospital nurse staffing ratios mandated in California are associated with lower mortality and nurse outcomes predictive of better nurse retention in California and in other states where they occur.”
When discussing her research on the subject, Dr. Aiken said, “One of the best natural experiments occurred when California enacted mandated nurse-to-patient ratios. Almost 15 years later, California still has the best nursing-staffed hospitals in the country. The state has seen steeper declines in mortality and improvements in other indicators than other states.”
The Human Impact
Despite overwhelming evidence that safe staffing ratios in all clinical settings—including nursing homes—improve health outcomes, prevent complications, and early death for residents, the US government continues to create policies aligned with the interests of the ultra-wealthy at the cost of the American people. Because when legislators fail to do their duty, patients and care workers pay the price.
When there are not enough registered nurses in LTC settings–professionals trained to identify subtle changes in medical status and intervene–that crucial responsibility gets pushed on other care workers who are not equipped to handle it. This toxic cycle contributes to high rates of burnout, exhaustion, and stress for the CNAs and LPNs who are the beating heart of nursing home care.
Peter Murphy Lewis is a former CNA, long-term care advocate, and the executive producer and host of the award-winning docuseries “People Worth Caring About.” The series follows caregivers in the healthcare industry who rarely get the coverage or the recognition they deserve. Caregivers like Chris, a medication aid of 33 years at the Brookstone View long-term care facility in Broken Bow, Nebraska.
“For veterans like Chris, the absence of a 24/7 RN isn’t just a policy change, it’s a spike in his personal legal liability. When aides are left to manage complex medication regimens without an RN’s immediate support, we risk losing the very ‘pipeline’ we are trying to build; currently, 20 percent of potential caregivers already cite this systemic strain as a reason to avoid the field,” Lewis says.
Meg Lambrych, RN
WriterMeg Lambrych is a registered nurse, writer, and nursing advocate from Upstate New York.
After leaving clinical care due to burnout, she dedicated her life to covering issues in healthcare, nursing, and health in the digital space. She reports on nursing culture, policy, and history and interviews nursing innovators and leaders shaping the profession and challenging the status quo.