In a summary judgment decision released on April 7, 2025, Judge Matthew J. Kacsmaryk ruled that the Centers for Medicare & Medicaid Services (CMS) exceeded its statutory authority and violated the language of the Nursing Home Reform Law when it issued a final nurse staffing rule that required registered nurses around the clock and at least 3.48 hours per resident day (HPRD) of nurse staffing time. American Health Care Association, et al v. Kennedy, Nos. 2:24-CV-114-Z-BR and 2:24-CV-171-Z (consolidated) (Amended Complaint) (N.D. Texas, Jun. 18, 2024). The federal district court decision stated, “CMS lacks authority to issue a regulation that replaces Congress’s preferred minimum hours [eight consecutive hours of registered nurse time per day] with its own [24 hours per day].” On the same basis and with the same analysis, the Court vacated the rule’s HPRD requirement. Judge Kacsmaryk left the remainder of the final rule intact, the enhanced requirements for the facility assessment process (42 C.F.R. §483.71) and the payment transparency reporting requirement (42 C.F.R. §442.43).
As the Center for Medicare Advocacy (“Center”) reported when the American Health Care Association (AHCA) and others filed the case challenging the staffing rule in May 2024, plaintiffs selected a friendly forum for the litigation. The Center wrote:
Taking no chances about which judge would be assigned to hear the case, the trade associations filed their lawsuit in a division of the federal court in northern Texas that has only a single district judge, Matthew Kacsmaryk. Judge Kacsmaryk has presided in multiple contentious health care cases in which he has ruled against the government. The Judicial Conference has been critical of judge-shopping and, on March 12, 2024, “strengthened the policy governing random case assignment, limiting the ability of litigants to effectively choose judges in certain cases by where they file a lawsuit.” The U.S. District Court for the Northern District of Texas, however, has so far declined to follow the new guidelines.
Judge Kacsmaryk’s summary judgment decision was not a surprise.
On April 3, four days before the summary judgment decision was issued in Texas, the federal government filed a brief strongly supporting the staffing rule in a different case in the Eighth Circuit Court of Appeals. State of Kansas v. Becerra, Civ. A. 1:24-cv-00110-LTS-KEM (N.D. Iowa, Oct. 8, 2024), the third nursing home industry lawsuit, challenged the entire staffing rule, including the enhanced facility assessment process and the payment transparency reporting. On January 16, 2025, a district court in Iowa, denied plaintiffs’ motion for a preliminary injunction to stop implementation of the rule. “Court Denies Preliminary Injunction in Challenge to Nursing Home Staffing Rule” (CMA Alert, Jan. 16, 2025). The Center led a coalition of organizations in an amicus brief that urged the court to allow the staffing rule to take effect. The government’s April 3 brief in the Eighth Circuit, State of Kansas v. Kennedy, No. 25-1097, represents CMS’s ostensible support for the staffing rule.
Many advocates for nursing home residents believe that the Eighth Circuit filing does not reflect actual support for the staffing rule, but, rather, an interest in keeping the rule alive so that the savings from a Congressional repeal of the rule could be applied to the $880 billion in Medicaid cuts that Congress is requiring in the budget reconciliation process.
According to “Judge tosses nursing home staff rule in ‘major victory’ for sector,” McKnight’s Long-Term Care News (Apr. 7, 2025), AHCA and Leading Age, the nursing home trade associations that filed the court challenges to the staffing rule, reiterated their opposition to the staffing rule when they heard about the Texas ruling. AHCA’s CEO Clif Porter called on Congress to prohibit any staffing rule at any time in the future. AHCA’s members attending a meeting rose in a standing ovation on learning about the decision.
In a LinkedIn post, Sam Brooks, Director of Public Policy for the National Consumer Voice for Quality Long-Term Care, described the response of advocates for nursing home residents:
Sadly, the minimum staffing rule that would save the lives of 13,000 nursing home residents annually was vacated by a federal judge in Texas. This modest rule would prevent nearly 14,000 pressure ulcers, reduce hospitalizations, and make the lives of hundreds of thousands of nursing home residents better. Despite this ruling, we fight on to protect our most vulnerable citizens.
McKnight’s quoted Brooks, but ignored the first sentence of his statement, except for the word “sadly.” It omitted Brooks’ statement that 13,000 residents will die each year because the staffing rule has been vacated.
April 10, 2025 – T. Edelman