Senate’s Build Back Better Nursing Home Provisions Garners Varied Reactions

A Senate draft of the Build Back Better Act removed the teeth from a key nursing home provision – implementation of mandatory minimum staffing hours – a change eliciting mixed reactions from long-term care advocates.

The change was coupled with an added $800 million toward staffing and infection control in nursing homes, to be disbursed over the next decade.

In a Wednesday webinar Center for Medicare Advocacy officials expressed disappointment at the staffing mandate removal. The American Health Care Association and National Center for Assisted Living (AHCA/NCAL) issued a statement the same day, appreciative that the unfunded mandate was removed.


The provision originally required the U.S. Secretary of Health and Human Services to conduct a study to determine the right amount of hours for minimum staffing in facilities, with findings implemented by the Centers for Medicare and Medicaid (CMS) the following year.

The Senate version kept the survey, but dropped its implementation.

“We were really hopeful with the House bill. It’s not over, they’re all in conversation now. Maybe we can get that in again, especially if we’re going to give facilities another $800 million for staffing,” said Toby Edelman, senior policy attorney for the Center for Medicare Advocacy. “It’s very upsetting to have that lost, but it doesn’t mean that an administration couldn’t use those numbers to require staffing.”


Edelman said she’s seen this effort play out before, mentioning the Nursing Home Reform Act of 1987 that did not get a mandated staffing ratio. What was eventually passed sounds similar to what was left in the Build Back Better Act – a comprehensive analysis on staffing ratios published in 2001 with input from countries all over the world.

Still, the administration at the time said there wasn’t enough information to mandate a federal staffing ratio. The study found a total of 4.1 hours per resident day was needed for better care; that included all direct care workers, registered nurses (RNs), licensed practical nurses (LPNs) and certified nursing assistants (CNAs).

“I was really hopeful when we first saw [the provision]. Projections for 4.1 are not new. This is something that we’ve known, and that we know isn’t worth asking across the country, in all states,” added Mairead Painter, Connecticut long-term care ombudsman. “It’s really important that there is a requirement, that everyone has this standard and that it comes from our federal oversight agency.”

AHCA has been vocal about the nursing home provisions in the last several weeks. The organization agrees staffing ratios are needed, but cannot support the bill in its current unfunded state.

Operators will need to add 150,000 direct care workers to meet hourly requirements, Parkinson said in a November press conference, and at least 21,000 additional RNs to adequately provide around-the-clock care, referring to the other main provision requiring around-the-clock registered nurse (RN) care.

Each provision, if it remained unfunded, would cost the industry $10.7 and $2.5 billion per year, the association has said.

That’s on top of 220,000, or 14% of the skilled nursing workforce lost during the pandemic, according to recent data from the Bureau of Labor Statistics.

“We appreciate Senators removing an unfunded mandate to implement the findings of a minimum staffing study, as well as including an additional $800 million for states over the next decade to assist with improving staffing and infection control in nursing homes,” Mark Parkinson, president and CEO of AHCA, said in a statement.

“These are great first steps in recognizing our current labor crisis and the need to build up the next generation of long term caregivers. However, more work is needed to ensure the Build Back Better Act lives up to its name.”

Other provisions in the bill that affect nursing homes include: improving accuracy and reliability of nursing home data; ensuring accurate information in cost reports, survey and enforcement improvements; grants to improve staffing and infection control; and improvements to special focus facility (SFF) programs.

The Build Back Better Act (HR 5376), which broadly aims to expand the social safety net for millions of Americans, passed 220-213 in the House in mid-November.

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