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A group of Republican attorneys general have lost their bid for a temporary injunction that would have blocked the federal government from imposing new staffing level requirements on nursing homes.
Last year, the Biden administration approved new staffing requirements for nursing homes that collect taxpayer money through Medicaid and Medicare. The rules, which are to be phased in during the course of years, call for all such homes to have a registered nurse on site 24 hours per day, 7 days per week, and establishes specific hours-per-day minimums for other caregivers.
To ease the financial burden on nursing home operators, the federal Centers for Medicare and Medicaid Services allocated more than $75 million to initiatives intended to expand the nursing workforce. It also approved a process for waivers to be granted if homes tried but failed to find the required workers, and offered additional concessions for homes located in rural areas hard hit by workforce shortages.
Even before it was approved, the proposed rule was opposed by industry officials and GOP governors and attorneys general. In November 2023, Iowa Gov. Kim Reynolds publicly announced her opposition to the new staffing rule, joining 14 other Republican governors in signing a letter to President Joe Biden in which they argued the rule would “harm the seniors, elderly and disabled it’s designed to help.”
Last year, 20 GOP attorneys general and industry lobbyists banded together to challenge the staffing mandates through two separate court cases — one filed in Iowa, and one filed in Texas.
At the time, Iowa Attorney General Brenna Bird said she would be leading the Iowa court challenge of the staffing mandates in order to ward off a “mass shutdown of nursing homes” and to “stop the Biden-Harris attack on senior care that will force nursing homes out of business.”
Bird and the other plaintiffs argued CMS lacks the authority to impose staffing requirements on taxpayer-funded nursing homes and that the new rule is arbitrary and capricious. They then filed a motion seeking a temporary injunction that would block implementation of the new rule while the larger issues in the case are litigated.
In order to obtain such an injunction, the plaintiffs had to show nursing home operators would suffer irreparable harm from the financial burdens caused by implementation of the rule.
In court filings, they alleged that Iowa nursing homes were already “attempting to hire RNs over LPNs whenever possible” and that they were “engaging in aggressive recruitment strategies such as sign-on and recruitment bonuses,” all of which were adding to their expenses. They also argued that more than 70% of the homes in Iowa would be affected by the rule, causing an estimated “state financial impact” of more than $25 million.
The federal government argued that any harm suffered by the plaintiffs was “purely economic” and self-inflicted.
In his decision siding with the federal government, United States District Judge Leonard T. Strand stated that “with regard to nearly every aspect of the final rule, the plaintiffs have failed to demonstrate that a preliminary injunction is necessary in order to preserve the status quo and prevent irreparable harm.”
Even if one accepts the claim of financial burden, Strand stated, the 24/7 requirement on registered nurses and the minimum hours-per-day requirements don’t begin to take effect until May 2026, at the earliest. Because of that, he said, the industry’s financial-burden arguments were “too speculative to constitute irreparable harm,” at least when determining whether a preliminary injunction is warranted.
As for the argument that the industry is facing a nationwide workforce shortage, Strand stated that the staffing-level rule “did not create the workforce shortage in the healthcare industry.” He said the workforce argument could, however, be raised by the plaintiffs as the case proceeds and the court considers whether the new rule is arbitrary and capricious.
Bird’s office declined to comment Thursday on Strand’s ruling.
Iowa homes cited for staffing violations
According to data from the Centers for Medicare and Medicaid Services, 14% of Iowa’s 422 nursing facilities were cited for insufficient staffing in fiscal year 2023 before the new requirements were enacted. That was more than double the national average, which was 5.9%.
Only five other states – Hawaii, Michigan, Montana, New Mexico and Oregon — had a worse record of compliance with the staffing requirements that were in place at that time.
For decades, the government has required only that nursing homes provide “sufficient” staff to meet residents’ needs but has left it largely to owners to define “sufficient.” Federal data indicates many nursing homes already meet some of the new rule’s specific standards, and, on average, those that operate as nonprofits actually exceed the newly mandated staffing ratios.
In court briefs, advocates for the elderly have argued that the new rule could save 13,000 lives per year and that understaffing has been a longstanding problem leading to widespread injuries and death inside taxpayer-supported nursing homes, many of which are now run by private equity firms.
Strand’s ruling isn’t likely to have any direct impact on the Texas lawsuit, which was initiated by the American Health Care Association, a lobbying organization that primarily represents for-profit nursing homes.
Some observers say neither case is likely to have much effect on the long-term fate of the staffing mandates since the Trump administration is expected to do away with the new rule once the president-elect takes office.
This story was originally produced by the Iowa Capital Dispatch which is part of States Newsroom, a nonprofit news network, including the Daily Montanan, supported by grants and a coalition of donors as a 501c(3) public charity.