Iowa federal judge blocks Biden nursing home staffing rules

A federal judge in Iowa has blocked key parts of a Biden administration rule mandating minimum staffing levels in nursing homes across the country.

The judge ruled that the Centers for Medicare and Medicaid Services (CMS) exceeded its authority by implementing the staffing requirements. The ruling follows a similar decision by a Texas judge in a separate lawsuit and adds to the legal challenges against the federal nursing home staffing mandate.

Specifically, the Iowa judge vacated the provisions that required a registered nurse (RN) on-site 24/7 and a minimum total of 3.48 hours of nursing care per resident per day. The judge’s order allows other parts of the rule, such as facility assessment and state Medicaid reporting requirements, to stand.

Congress imposed uniform staffing requirements on long-term care (LTC) facilities that participate in Medicare and Medicaid by requiring skilled nursing facilities to provide 24-hour nursing services sufficient to meet nursing needs of its residents and mandating an registered nurse be on duty at least eight hours per day.

U.S. District Judge Leonard Strand, in Iowa’s Northern District, said CMS’s general rulemaking authority “does not permit it to override explicit Congressional statutory commands“

"When Congress has already legislated, the agency cannot substitute its judgment for that of the legislature,“ Strand wrote.

The ruling is considered a significant victory for nursing home operators who had challenged the mandate, saying it is unworkable given ongoing labor shortages.

The nursing home industry generally opposed the mandate, saying that it would be to costly and difficult to implement, potentially leading to facility closures and reduced access to care. CMS had argued that the staffing requirements were necessary for resident safety and improved patient outcomes.

President Donald Trump’s administration is appealing the Texas court's decision that struck down the Biden administration's nursing home staffing mandate, and may do the same in Iowa. The U.S. Department of Health and Human Services is now taking the Texas case to the Fifth Circuit Court of Appeals.

The federal Minimum Staffing Standards rule, issued in 2023, sought to “improve the safety and quality of nursing home care” by elevating and providing uniform standards across the country “to ensure safe and quality care.” The rule provided exemptions for facilities facing workforce shortages, and followed research finding that lower staff ratios led to worse patient health outcomes.

Republican Iowa Attorney General Brenna Bird co-led a multi-state lawsuit, joined by 19 other states in suing to block the law.

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Bird and the Republican-led states argued the increased nursing requirements were estimated to cost more than $43 billion and risked closing many nursing homes, especially in rural and low-income communities, and intrude into an area typically within states’ domain.

“The $43 billion cost, the risk of widespread LTC facility closures and the fact that many states have adopted their own staffing standards while Congress has not done so all support finding this to be an extraordinary case,” Strand wrote in his order. “ … CMS’s general rulemaking power … does not constitute clear authorization to mandate rigid staffing requirements for LTC facilities.”

Bird, in a statement Thursday, heralded the ruling a victory for Iowa seniors and their families.

“The mandate would have forced many nursing homes out of business, increased costs for families, and, for some, removed access to senior care altogether,” Bird said. “Our seniors have invested their lives in their communities; I’m proud to have helped protect their access to quality care close to home.”

Brent Willett, president & CEO of the Iowa Health Care Association that represents Iowa’s nursing home industry, praised the judge's ruling and the lawsuit brought by Bird and the other Republican attorneys general in a statement to The Gazette.

"This mandate was never constitutional,“ Willett said. ”Left unchallenged, the federal government’s unprecedented mandate would have throttled access to long-term care in thousands of American communities. We applaud the court’s decision, which allows providers, educators and policymakers to get back to work on real solutions to the acute staffing crisis providers across the country face as we prepare for an influx of long-term care demand from a rapidly aging population in the coming decades."

John Hale is co-owner of The Hale Group, an Ankeny-based advocacy firm focused on older Iowans, Iowans with disabilities and the caregivers who support them.

Hale called Wednesday’s ruling “a huge loss for nursing home residents.”

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“Every bit of reputable research conducted over the past decade have clearly shown residents of nursing homes are safer, they are healthier and they are happier when there are more staff on duty to assist them and simply spend time with them,” he said. “Every family member with a loved in a nursing home knows that. This is simply common sense.”

If the industry offered better pay, benefits, training and advancement opportunities, more workers would seek jobs in nursing homes, Hale said in response to industry concerns over worker shortages.

Hale, too, argues nursing facilities have closed not due to an inability to find staff, but out-of-state owners and investors unhappy with the profits being generated, and people are choosing to live elsewhere.

“More and more want to be served in their own homes and in their own communities, not in an institutional setting,” he said. “The industry is rapidly evolving. Their first choice is to live in their own home, if possible, and their second choice is an assisted living facility that costs significantly less, and the last option is a nursing home.“

Comments: (319) 398-8499; tom.barton@thegazette.com