Fifteen Governors Challenge Biden on 'Unrealistic' Staffing Mandate, Citing Disruption to State Initiatives

A coalition of fifteen governors has confronted President Biden over an 'unrealistic' staffing mandate for nursing homes, arguing it undermines state-level initiatives. They assert that this one-size-fits-all federal directive could unravel the progress made in addressing health care staffing shortages at the state level.

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Fifteen Governors Challenge Biden on 'Unrealistic' Staffing Mandate, Citing Disruption to State Initiatives
6 Min Read November 4th, 2023

Fifteen Republican governors have appealed to President Joe Biden this week to reevaluate the federal staffing mandate proposed for the nation's 15,000 nursing homes. In a letter to the White House on November 1, the governors highlighted the risk of potential closures and the expected $4 billion yearly expense, which they anticipate will burden taxpayers and public and private health plans.

The governors accused the proposed rule of oversimplifying a multifaceted issue, one they have been addressing through various measures to provide adequate staffing for care facilities. "This approach is not only impractical, but it also risks undoing our efforts and could ultimately harm the very individuals it aims to protect," they stated, pushing for a constructive dialogue between state and federal governments on serving long-term care residents.

This plea coincides with escalating congressional actions as the comment period for the rule draws to a close on Monday. According to Roll Call, a news source for Congress members and staff, Republican Rep. Greg Murphy (R-NC) intends to propose an amendment by the November 3 deadline to a labor, health, and education funding bill that would block or restrict the staffing mandate, halting funding for the bill's implementation.

Medicare and Medicaid Primary Payers of Nursing Home Care in the U.S.

The problem is significant as more people need long-term care services, and quality of care is of utmost concern. Longevity and improvements in medical science have meant that we are living longer than ever before, and many people are living with chronic conditions that require long-term care or supervision due to cognitive decline.

Medicare and Medicaid are the primary payers of nursing home care in the United States, covering approximately 70% of all nursing home costs. Private pay and Long-Term Care insurance cover the remaining 30% of costs. Keep in mind that most long-term care is provided at the care recipient's home or adult day care centers and assisted living facilities, not in nursing homes. Generally, only Long-Term Care Insurance will pay for that care or be paid from the income and assets of the care recipient. However, there is some limited Medicaid coverage for these services in some states.

Medicare covers short-term nursing home care after a hospital stay. It also covers hospice care for people who are terminally ill.

To qualify for Medicare coverage of nursing home care, you must:

  • Have been discharged from a hospital within the past 30 days.
  • Need skilled nursing care that cannot be provided at home.
  • Have a doctor certify that you need skilled nursing care.

Medicare covers up to 100 days of skilled nursing care per benefit period. A benefit period begins the day you are admitted to a hospital and ends 60 days after you are discharged. If you need more than 100 days of skilled nursing care, you may be able to qualify for coverage through a Medicare Advantage plan, but it is very limited.


Medicaid is a joint federal-state health insurance program for low-income individuals and families. Medicaid covers long-term nursing home care for people who meet certain financial and medical requirements.

To qualify for Medicaid coverage of nursing home care, you must:

  • Meet your state's income and asset limits.
  • Need a level of care that can only be provided in a nursing home.

Medicaid is the largest payer of nursing home care in the United States, covering approximately 60% of all nursing home costs.

How Will CMS React?

It was uncertain how the initiative by Rep. Greg Murphy might impact the plans of the Centers for Medicare & Medicaid Services (CMS), which has not proposed any additional funding to meet the staffing requirements of the rule. Although CMS has suggested allocating $75 million towards a nursing training program, this funding is expected to be sourced from the agency's existing Civil Monetary Penalties Fund, not new spending.

Leading Republicans from the House Energy and Commerce, House Ways and Means, and Senate Finance committees have also contacted various agency leaders this week to advocate for the retraction of the staffing rule.

The Republican governors, in their correspondence, criticized the CMS mandate for its generalized approach, which they believe does not consider the specific needs of individual facilities or the nuances of different communities.

They argued that the mandate overlooks distinct regional and economic circumstances, noting that 38 states have already customized their staffing regulations to accommodate the diverse conditions within each state. "CMS's broad requirement simply overrides these tailored approaches," they asserted.

Governors from a consortium of 15 states, including Georgia, Indiana, Iowa, Mississippi, and others, signed the letter. They detailed state-level initiatives to tackle the significant health care staffing challenges they face.

Addressing President Biden, the governors underscored that the shortage of nursing staff is a longstanding issue and that their states are actively investing resources to resolve it. They described efforts to inspire young individuals to choose health care professions, collaborating with the industry to enhance nursing education, providing grants to employ additional nursing staff, and initiating innovative health care apprenticeship programs that begin in high school.

The letter reads:

As governors, we are committed to protecting the health and safety of all our citizens, including those in nursing homes in our states. On September 1, 2023, the Centers for Medicare and Medicaid Services (CMS) proposed new regulations for long-term care facilities that impose unnecessary, one-size-fits-all staff requirements. If adopted, CMS’s proposed regulations will force many long-term care facilities in our communities to close, eroding access to health care for some of our most vulnerable citizens.

America’s long-term care industry is facing a full-fledged workforce crisis, hitting lows not seen since 1994. Between February 2020 and December 2022, facilities lost more than 200,000 workers, and industry observers view long-term care as among the hardest hit sectors in health care that has still not recovered from the COVID-19 pandemic. Such challenges are especially acute in rural areas. Despite this, the CMS requirements would force over 80% of facilities nationwide to hire more staff at a time when workers, particularly RNs, have never been scarcer.

In short, Republican governors are pulling multiple levers to ensure these facilities have the staff they need to care for their vulnerable residents. In contrast, your proposed rule treats this complex, deep-rooted problem as something to be solved with a simple wave of the bureaucratic wand. This is not only unrealistic, but it also threatens to unravel the work we have done, while harming the seniors, elderly, and disabled it’s designed to help. We urge you to reconsider your commitment to unfunded mandates and instead enter into a genuine state-federal dialogue on how best to serve residents of long-term care facilities in our states.

Governors from Georgia, Indiana, Iowa, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, Oklahoma, South Carolina, South Dakota, Tennessee, Texas and Wyoming signed the letter.

American Families Spending Savings on Long-Term Care

According to a 2022 study by the Kaiser Family Foundation, nearly half (47%) of all people who enter nursing homes in the United States spend down their personal savings and must rely on Medicaid to pay for their care. This number has been increasing in recent years as the cost of long-term care has continued to rise.

The study also found that people of color and women are more likely than white men to spend down their savings and rely on Medicaid for long-term care. This is likely due to a number of factors, including lower incomes, shorter life expectancies, and higher rates of chronic health conditions.

The high number of people who spend down their savings due to long-term care is a significant financial burden for individuals and families. It can also lead to delays in accessing care, as people may wait until they have exhausted all of their other resources before applying for Medicaid.

LTC Insurance - Partnership Benefits Help Families Preserve Assets

There are many Americans who are unaware of Long-Term Care Insurance or the partnership program that provides additional dollar-for-dollar asset protection.

Long-Term Care Insurance helps pay for the costs of long-term care, not just nursing home care or assisted living, but in-home services and adult day care as well. LTC Insurance can be a valuable tool for families trying to protect their assets from the high cost of long-term care.

Partnership benefits are a special type of LTC policy benefit that is offered in most states. Partnership benefits allow LTC policyholders to qualify for Medicaid while retaining some of their assets. This can be a significant benefit for families who are trying to preserve their assets and avoid having to spend down to the Medicaid asset limit.

Issues with LTC Insurance

One of the problems of Long-Term Care Insurance is that individuals must purchase a policy before they have failing health or an age-related issue. 

Some believe LTC Insurance policies are expensive; however, premiums vary dramatically between insurance companies and benefit levels. In addition, premiums are also determined by your age, health, and even, in some cases, family history.

As a result, most people obtain coverage in their 40s or 50s. However, if someone has fairly good health, affordable options are available in their 60s and even to some degree at older ages.

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Finding Quality Care for Mom or Dad

LTC NEWS offers help for you and your family in many ways. The LTC NEWS Caregiver Directory is an excellent resource where you can find the most comprehensive directory of all types of long-term care services no matter where your loved one lives - Long-Term Care Services Directory | Find Care Near You.

If your loved one has an LTC Insurance policy, that will open the door to many quality care options, as one of the first questions most home health agencies and long-term care facilities will ask you is if the care recipient has an LTC policy.

Be sure to use the benefits from a loved one's LTC policy; trying to save them for later is not a good approach since access to quality care improves a person's quality of life immediately.

LTC NEWS has combined efforts with Amada Senior Care, a leading in-home health care agency with locations throughout the country, to help you process a claim from any LTC Insurance policy.

There is no cost or obligation for this service - Filing a Long-Term Care Insurance Claim

If they don't have an LTC policy, Amada can still help develop a plan of care and provide you with many affordable in-home care options. 

Learn more now - Find Quality In-Home Care.

These LTC NEWS guides will assist you in trying to find appropriate long-term health care services for a loved one:

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