‘Access Crisis Unfolding’: Nursing Home Operators, Advocates Warn of Dire Effects from Biden’s Order on Staffing

President Joe Biden’s executive order that aims to implement minimum staffing standards and tie Medicare payments to staff retention drew frustration from nursing home industry operators and advocates, who said that the well meaning directives would likely compound the staffing crisis and lead to closures unless policies are aimed at resolving its root causes, and not penalizing nursing homes.

Without policies and solutions – and funding – that allows for better paying jobs in the sector, the White House position may not serve to improve the quality of care either, they argue.

However, in signing the executive order Tuesday afternoon, Biden said funding wasn’t forthcoming.


“The executive order doesn’t require any new spending. It’s about making sure taxpayers will get the best value for the investments they’ve already made,” Biden said during a speech in the White House Rose Garden. “We’re going to improve long-term care by strengthening staffing standards at nursing homes. And I’ve also instructed the Department of Health and Human Services to figure out how home care workers can get the pay they deserve with the money already allocated.”

Funding for Biden’s plans in the executive order – which includes 50 different directives to federal agencies to address affordability and quality of child care, long-term care for aging and disabled adults, and job quality of the care workforce – will come from existing sources such as the American Rescue Plan. “Those will also help states expand and strengthen Medicaid home care programs,” Biden said in his speech.

The White House plans to enact executive actions to improve care, directing the Department of Health and Human Services (HHS) to “build” on the minimum staffing standards and base a portion of the Medicare payments on retention of workers at nursing homes, a White House fact sheet stated prior to the signing ceremony.


Aside from funding, many questions surrounding the execution of the proposed actions, such as how Medicare rates will exactly get impacted if nursing homes fail to retain a certain level of workers, remained unanswered, especially in light of the Centers for Medicare & Medicaid Services (CMS) still mulling a federal minimum staffing standard.

“We’ve known for months that CMS is developing minimum staffing [regulations]. So, in effect, the White House is telling CMS to do what it already was doing. But until we see the new rules, there is no way to answer [such] questions,” Howard Gleckman, Senior Fellow at the Urban Institute and a regular Forbes contributor focusing on long-term care issues, told SNN.

In its latest Medicare proposed payment update for skilled nursing facilities, CMS said it expects to publish the minimum staffing rules this spring. The agency has been studying the issue and formulating its proposal as part of a large-scale nursing home reform push that the White House began in February 2022.

Advocates for nursing homes pushed back against burdening nursing homes further, calling the latest efforts ‘punitive.’

“The administration is still getting it wrong on nursing homes … Already, nursing homes around the country are closing or limiting admissions due to staffing shortages. Why take that option away from the people who need it by implementing punitive policies that potentially worsen, rather than remedy, the ongoing staffing crisis? We are particularly concerned by the threat of withholding Medicare payment if providers don’t have workers – when workers simply don’t exist,” said Katie Smith Sloan, president and CEO of LeadingAge, the association of nonprofit providers of aging services.

Saying that a solution to the workforce crisis is “desperately” needed, Smith Sloan called for action on immigration, as a means to bring “ready and willing” workers to the field through “proven programs and pathways.”

The White House fact sheet also noted that long-term care costs are up 40% over the past decade, while wages for nursing home workers have remained stagnant.

“[Many] workers providing this critical care find themselves in low-paying jobs with few benefits,” the fact sheet stated. “Care workers, who are disproportionately women of color, struggle to make ends meet, and turnover rates are high.”

‘Access crisis unfolding’

Operators like the Evangelical Lutheran Good Samaritan Society reiterated calls for any federally mandated workforce initiative on staffing minimums to be supported by funding, particularly in the most vulnerable rural communities, which have been worst affected by closures.

“We foresee an access crisis unfolding if an unfunded, one-size-fits-all minimum staffing requirement is enforced in skilled nursing facilities. Unfortunately, our nation’s seniors will pay the price,” Nate Schema, president and CEO of the Good Samaritan Society, told SNN. “There simply are not enough workers available to meet any requirement to increase staffing levels. Setting unattainable staffing ratios will result in seniors having fewer options for care close to home due to closures and facilities’ reduced capacities to accept admissions.”

Sioux Falls, South Dakota-based Good Samaritan Society is in the process of reducing its footprint from 22 states to seven, although it will remain one of the nation’s largest nursing home operators even after this reduction of its portfolio.

Nursing homes in rural states will be the hardest hit if a staffing mandate were to go into effect. Approximately 70% of the Good Samaritan Society’s long-term care residents live in rural communities across the country, and Schema said, “A staffing mandate without the support and resources needed to address our workforce crisis will exacerbate the access challenges that already disproportionately impact seniors living in these rural communities.”

Schema said the Biden administration should work on “strengthening the pipeline of workers, creating incentives to recruit new people to our sector and expanding flexibilities afforded through the Public Health Emergency.”

To this end, Biden said: “To ensure we have enough care workers, we’re expanding partnerships with community colleges, registered apprenticeship programs and the AmeriCorp.”

The White House fact sheet said the administration is encouraging “apprenticeship programs and partnering with employers, unions, and others to recruit, train, and keep long-term care workers on the job while also helping them advance their careers as registered and licensed nurses.”

‘The root causes’

Schema and advocacy groups cited the desire to work with the Biden administration on developing policies and programs, but said current proposals don’t address the ‘root causes’ of the staff crisis.

“We are supportive of incentivizing providers to improve on key quality metrics, including staff turnover,” Holly Harmon, senior vice president of Quality, Regulatory, and Clinical Services the American American Health Care Association and National Center for Assisted Living (AHCA/NCAL) said in an emailed statement to SNN, adding, “At the same time, we need policymakers to offer programs and solutions that will help us attract and retain caregivers to ensure residents are well supported. Turnover metrics are important, but we need significant meaningful aid to help address the root causes of turnover and offer more competitive, good-paying jobs. We look forward to reviewing the executive order and working with the Biden Administration on how we can improve the entire long term care continuum.” 

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