The number of states challenging the federal minimum staffing mandate has now grown to 21 states, after 20 states filed a joint lawsuit.

As of Tuesday, Iowa’s attorney general was the latest to sue the Biden-Harris administration, challenging the nursing home federal minimum staffing mandate along with Kansas, Virginia, South Carolina, and other mostly Republican-led states. Other states seeking to dismiss the mandate include Alabama, Alaska, Arkansas, Florida, Georgia, Idaho, Indiana, Kentucky, Missouri, Montana, Nebraska, North Dakota, Oklahoma, South Dakota, Utah, and West Virginia.

The staffing mandate sidesteps Congress and exceeds the Centers for Medicare & Medicaid Services’ (CMS) authority, according to the lawsuit, while also posing an “existential threat” to the industry as many facilities continue to struggle with staffing issues. They’ll have no choice but to go out of business, the plaintiffs claim, should the mandate go through.

All in all, plaintiffs challenging the mandate represent a diverse group of states, with Texas being the first among states to file a lawsuit, as well as industry organizations, such as The American Health Care Association (AHCA) and all state chapters for LeadingAge, along with some individual facilities.

CMS’s “wafer-thin” reliance on a vague statutory provision shouldn’t allow the agency to promulgate a final rule that conflicts with a separate Congressional statute, according to the lawsuit. Plaintiffs refer to a “miscellaneous” rulemaking provision that allows the Secretary of Health and Human Services (HHS) to impose “such other requirements relating to the health and safety of residents or relating to the physical facilities thereof as the Secretary may find necessary.”

“Congress did not intend CMS to pull such an ‘elephant’ of a mandate out of the ‘mouseholes’ of either the Medicare or Medicaid Acts,” plaintiffs said.

Craig Conley, shareholder at law firm Baker Donelson, said he wasn’t surprised to see the Iowa lawsuit, which is similar to lawsuits in other states that cite concerns over the mandate leading to a crisis of access.

“The claims are very similar with the focus being on the potential financial peril that the mandate may cause within the industry, thereby reducing the number of facilities available to the public,” said Conley. In other words, the ripple effect of the mandate may cause facility closures resulting in less options for the people needing care within a long-term care facility.

Conley said it’s interesting that the lawsuits have been filed in mostly Republican-led states, where the chance of derailing the mandate will be higher. He suspected that any decisions made at the trial court level will be appealed and may end up before the US Supreme Court.

The Iowa Health Care Association said they appreciate the state’s interest in stopping a “devastating and illogical rule,” IHCA President and CEO Brent Willett said in a statement. The association stands behind AHCA and its suit and hope it will be litigated and won as soon as possible, rendering other suits unnecessary and lending some stability to the sector.

“Our seniors spend a lifetime investing in our communities,” said Iowa Attorney General Brenna Bird. “Now, we need to invest in them by ensuring they have access to the care they need. I am suing to stop the Biden-Harris attack on senior care that will force nursing homes out of business, increase costs for families, and remove access to senior care altogether.”

This most recent lawsuit comes less than a month after the Texas and AHCA lawsuits were consolidated into one, and CMS filed its lengthy administrative record for its defense of the nursing home staffing mandate.

And earlier this year, the Supreme Court’s decision to discard long-standing Chevron doctrine opened the door for further litigation against the mandate, with Texas filing its lawsuit months later.

“With the demise of the Chevron deference, the positions of the states may be bolstered as a result since courts can overturn actions by agencies such as CMS if they have exceeded the powers delegated to them by Congress,” said Conley.

The latest SCOTUS decision is expected to impinge on the powers wielded by federal agencies following the 1984 Chevron ruling involving the energy giant. Then, the court found that government agencies were best positioned to interpret the federal statutes, provided the interpretation was reasonable, according to the Harvard Gazette.

With SCOTUS throwing out the Chevron doctrine, legal experts told SNN that CMS’ influence over reimbursement rates, staffing levels and other areas of regulation can now be more easily challenged, on top of the mandate.