Evaluating the impact of state nurse staffing mandates on nursing homes over a 14-year period, researchers find that “staffing mandates were effective at increasing staffing levels but had no detectable effect on nursing home finances and did not lead to nursing home closures.” Rachel M. Werner, Xinwei Chen, Norma B. Code, Andrew R. Olenski, “State Nursing Home Minimum Staffing Mandates: Increased Staff Levels, Minimal Impact On Finances And Closures, 2010-23,” Health Affairs (Mar. 2026).
Specifically, comparing 4,551 nursing homes in 11 states that implemented or updated mandatory nurse staffing standards, between 2010 and 2023, with 2,298 facilities in 11 states that did not have a staffing mandate in the 14-year period, researchers find that, in states with staffing mandates:
- Nurse staffing levels increased by 0.18 hours per resident day, by about 5% per day and 8% before the COVID-19 pandemic (increasing 0.13 HPRD (5.7%) for certified nurse aides and 0.06 HPRD (7.5%) for licensed practical nurses)
- there was “no statistically significant changes in the probability” of reporting “a positive profit margin” and no change in facilities’ net margins (While nursing homes had an increase in direct care expenses of $273,000, they had a $546,000 increase in net patient revenues)
- there was no meaningful change in the number of nursing home closures
The study debunks nursing home industry arguments that were made in opposition to the final nurse staffing rule that was promulgated in 2024. The Administration repeated these arguments in its 2026 interim final rule with comment period repealing the staffing rule.
Discussing their findings, the researchers describe prior research findings that, faced with state-level nurse staffing mandates, some nursing homes shift away from registered nurses and toward “lower-skill workers” and cut back on non-direct staff, including housekeeping, food services, and activities staff. The Center for Medicare Advocacy encourages states considering staffing legislation to skillfully draft legislation to address and prevent these shifts and cutbacks.
The study also identifies factors that may have resulted in additional revenue to facilities, including increased Medicaid rates, increased admissions of Medicare beneficiaries, implementation of the new Medicare Part A reimbursement system (Patient Driven Payment Model), and COVID-19 relief funds. The researchers used “the only national source of information on nursing homes’ financial health,” the Healthcare Cost Report Information System (HCRIS) to identify facility finances, but recognized that the HCRIS data are self-reported and unaudited. In addition, they cite the “significant lack of transparency around nursing home costs and finances” and “substantial hidden profits from related party transactions.”
Recognizing challenges that nursing homes face in maintaining sufficient numbers of staff, the researchers recommend paying higher wages and benefits, unionization, and easing immigration restrictions.
The researchers conclude:
We found that state nursing home staffing mandates were effective at increasing staffing levels but had no detectable effect on nursing home finances and did not lead to nursing home closures. These results suggest that more widespread use of staffing mandates could benefit residents without harming nursing homes.
Predictably, the nursing home industry criticizes the research. Rachel Reeves, American Health Care Association (AHCA), describes staffing mandates as “‘an antiquated approach in today’s healthcare space.’” James Berklan, “Providers tear into study alleging no financial harm from nursing home staffing mandates,” McKnight’s Long-Term Care News (Mar. 3, 2026). Jodi Eyigor, LeadingAge, comments that the federal staffing rule required that nursing homes have registered nurses (RNs) on-site 24 hours per day, a “‘rigid’” requirement when “‘the nation is already facing significant RN shortages.’” Eyigor ignores Leading Age’s and AHCA’s jointly proposed “Care for Our Seniors Act; Improving America’s Nursing Homes By Learning From Tragedy & Implementing Bold Solutions For the Future” (2022), which explicitly called for 24 hour RN coverage (“24-Hour Registered Nurse (RN): Research shows a positive association between RN hours and overall quality. We support a new federal requirement that each nursing home have a [sic] RN on-staff 24 hours a day and will provide recommendations on how to effectively implement this requirement.”)