The Biden administration’s controversial nursing home staffing requirement was vacated late Monday by a federal judge in Texas, who ruled that the Department of Health and Human Services (HHS) had exceeded its statutory authority on the issue.
The heightened staffing requirements were finalized in April 2024 and had a multiyear phase-in set to begin in 2026. It would require nursing homes receiving Medicare and Medicaid funding to have at least one registered nurse on-site 24 hours a day plus other minimums including a total nurse staffing standard of 3.48 hours per resident per day.
The Biden administration’s proposed and final versions of the mandate were sharply decried by industry groups and congressional Republicans, who said the staffing requirements were unrealistic given the current costs of nursing labor and would push many facilities out of business.
The Centers for Medicare & Medicaid Services (CMS) had predicted that its proposed rule would require three-quarters of all nursing homes to increase hiring, a roughly $4 billion collective expense. An industry-backed analysis of the proposal, meanwhile, found that 94% would have to increase staffing and upped the estimate to $6.8 billion, with a warning that nursing homes could choose to trim their resident head counts rather than increase hiring and potentially leave hundreds of thousands displaced.
The American Health Care Association (AHCA), a nursing facility trade group, and Texas Attorney General Ken Paxton filed lawsuits to block the final rule, which were consolidated and considered for Monday’s summary judgment. Congressional Republicans had also signaled interest in legislating against the increase while Democrats sought to protect it—a divide that came up repeatedly during the confirmation of new CMS Administrator Mehmet Oz, M.D. (who did not endorse the mandate when questioned and instead pointed to technologies like telehealth as a potential solution for understaffing).
But lawmakers and the new administration were beat to the punch by Judge Matthew Kacsmaryk, of the U.S. District Court for the Northern District of Texas.
Kacsmaryk, a Trump appointee and a go-to judiciary for conservatives, focused on the parties’ arguments surrounding existing law on nursing home staffing requirements. For the 24/7 on-site requirement, that involved statute requiring facilities have “at least” eight hours of an on-site nurse. The defense argued by the HHS (under the Biden administration) had said the language was permissive of higher standards, while plaintiffs argued that it reinterpreted Congress’ intent. Kacsmaryk agreed with the latter.
Similarly, on the second statute challenged by plaintiffs regarding various hour per resident day requirements, plaintiffs argued that Congress had “opted for a flexible qualitative standard” with its requirement that nursing home provide services “sufficient to meet the nursing needs of [their] residents.” The judge ruled that the blanket minimum requirements of nursing hours do not take individual residents and facilities’ needs into account, and so were not consistent with the flexibility outlined in statute.
“Though rooted in laudable goals, the Final Rule still must be consistent with Congress’ statutes,” Kacsmaryk wrote in the order.
Kacsmaryk did not toss the entire final rule, but vacated the two provisions related to a 24/7 on-site nurse and minimum nursing hours per resident per day that were challenged by the plaintiffs.
The AHCA, in a release, applauded the ruling as “a victory for our nation’s seniors and their families. The court decision not only upholds the rule of law and balance of powers, but it protects access to care for our aging population. We appreciate Judge Kacsmaryk’s careful and thoughtful review of this case.”
Opposition to the staffing rule has been shared by the hospital lobby, which, in an amicus brief last year, reiterated criticisms of the “counterproductive” across-the-board staffing minimums. Supporters of the rule have included labor groups and patient advocacy organizations.
Ed Dudensing, an attorney whose firm has represented families in elder abuse cases against nursing homes and assisted living facilities, said in a statement that the judge’s decision “undermines the very safeguards designed to protect our elders’ dignity and well-being. Adequate staffing is a fundamental element of ensuring safe, respectful care, and it is incumbent upon our political leaders to work across differences to maintain and strengthen these standards.”
The judge’s decision could be appealed by the HHS, though it isn’t entirely clear that it will in light of Republicans’ opposition, Oz’s lukewarm position and President Donald Trump’s wide-reaching order to slash federal regulations.
On the other hand, the Department of Justice just last week argued in defense of the rule to the Eight Circuit Court of Appeals, which is considering a bid for an injunction in a separate lawsuit filed in a federal court in Iowa by 20 states and several industry associations. A federal judge rejected their push for a preliminary injunction back in January. Additionally, national labor group SEIU filed an amicus brief last month pushing back on the plaintiffs’ claims and arguing that a workforce shortage was the employers’ own doing.