In February 2026, University of Pennsylvania Leonard Davis Institute of Health Economics (LDI) Executive Director Rachel M. Werner, MD, PhD submitted a public comment to Centers for Medicare & Medicaid Services (CMS) opposing the repeal of the agency’s final rule “Medicare and Medicaid Programs; Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting,” which set minimum standards for staffing at long-term care facilities receiving Medicaid payment. 

The comment asserts that there is strong evidence that higher levels of direct-care staff in nursing homes improve the outcomes of nursing home residents,the rule is necessary to increase staffing levels, and there is no evidence to suggest that the CMS Minimum Staffing Rule would have a negative effect on nursing home finances or lead to closures. In the face of clear research that minimum staffing improves outcomes and saves lives, and lack of research that these mandates harm nursing homes, repealing this rule is not supported by evidence.

Views expressed by the researchers are their own and do not necessarily represent those of the University of Pennsylvania Health System (Penn Medicine).

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February 2, 2025

Department of Health and Human Services

Centers for Medicare & Medicaid Services 

7500 Security Boulevard

Baltimore, MD 21244

Re: CMS-3442-IFC

Dear Madam or Sir:

Thank you for the opportunity to comment on Interim Final Rule CMS-3442-IFC, “Medicare and Medicaid Programs; Repeal of Minimum Staffing Standards for Long-Term Care Facilities.” I am the Executive Director of the Leonard Davis Institute of Health Economics and Professor of Medicine at the University of Pennsylvania Perelman School of Medicine, the Robert D. Eilers Memorial – William Maul Mesey Professor in Health Care Management and Economics at the Wharton School, and a physician at the Philadelphia VA. My research examines the effects of health care policies and payment on health care delivery, using methods designed to draw causal inference from observational data. I am also a national expert in nursing home quality of care. I am an elected member of the National Academy of Medicine and previously served on the National Academies’ Committee on the Quality of Care in Nursing Homes, which produced the 2022 report The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff.¹

As a researcher and expert on long-term care quality and the relationship between payment practices and high-quality patient care, I oppose the repeal of provisions of the final rule titled “Medicare and Medicaid Programs; Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting,” which would have set minimum standards for staffing at long-term care facilities receiving Medicaid payment.

There is strong evidence that higher levels of direct-care staff in nursing homes improve the outcomes of nursing home residents. Research has shown that nursing home residents experience fewer bedsores and urinary tract infections in homes with more nurses and aides.² Higher staffing levels also improve functional status and reduce deaths.^3,4 My own analysis of the Minimum Staffing Proposed Rule projected that achieving the rule’s minimum staffing levels would avert approximately 14,215 pressure ulcers and save approximately 13,000 lives per year.^5,6 Virtually every state would benefit from enforcement of the CMS Minimum Staffing Rule, with California and Texas projected to save over 1,000 lives each if the rule were implemented.⁷

This rule is necessary to increase staffing levels. The fastest-growing age group in the United States is people age 65 and older, representing roughly one in six Americans, or 17% of the population. This proportion is projected to rise to 22% in 2040.⁸ Despite the enormous pool of potential nursing home residents, 83% of U.S. nursing homes had staffing levels below the CMS rule’s minimum for at least half of 2023; a full two-thirds had staffing levels below the minimum for all 12 months of 2023.⁹ Available evidence indicates that without enforcement of the CMS Minimum Staffing Rule, long-term care facilities will not meet the minimum staffing levels established by the rule. There is also strong evidence that nursing home staffing mandates are effective – when states implement staffing mandates, staffing levels increase.^10,11,12

There is no evidence to suggest that the CMS Minimum Staffing Rule would have a negative effect on nursing home finances or lead to closures. Early work on this subject found that staffing mandates did not lead to nursing home closures.¹³ Additionally, my own research, which will be published in the March 2026 issue of Health Affairs, demonstrates that state minimum staffing laws did not negatively affect nursing home finances or lead to nursing home closures. The CMS Minimum Staffing mandate is, however, likely to create jobs in the long-term care workforce. My work indicates that an increase of overall staffing to mandated levels would result in 46,868 more jobs.¹⁴

In the face of clear research that minimum staffing improves outcomes and saves lives, and lack of research that these mandates harm nursing homes, repealing this rule is not supported by evidence.

Thank you again for the opportunity to submit these comments.

Views expressed by the researchers are their own and do not necessarily represent those of the University of Pennsylvania Health System (Penn Medicine), the University of Pennsylvania, or the University of Pittsburgh.

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1. Committee on the Quality of Care in Nursing Homes, “The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff,” National Academies of Sciences, Engineering, and Medicine, June 27, 2022, https://doi.org/10.17226/26526.
2. Tamara R. Konetzka, Sally C. Stearns, and Jeongyoung Park, “The Staffing–Outcomes Relationship in Nursing Homes,” Health Services Research 43, no. 3 (2007): 1025–42, https://doi.org/10.1111/j.1475-6773.2007.00803.x.
3. Patricia K. Tong, “The Effects of California Minimum Nurse Staffing Laws on Nurse Labor and Patient Mortality in Skilled Nursing Facilities,” Health Economics 20, no. 7 (2011): 802–16, https://doi.org/10.1002/hec.1638.
4. Joel W. Cohen and William D. Spector, “The Effect of Medicaid Reimbursement on Quality of Care in Nursing Homes,” Journal of Health Economics 15, no. 1 (1996): 23–48, https://doi.org/10.1016/0167-6296(95)00030-5.
5. Rachel M. Werner, “Minimum Staffing Standards for Long-Term Care Facilities and Medicaid,” Leonard Davis Institute of Health Economics, March 26, 2025, https://ldi.upenn.edu/our-work/research-updates/briefing-nursing-home-staffing-mandate-and-resident-outcomes/.
6. Rachel M. Werner and Norma Coe to The Honorable Elizabeth Warren, July 8, 2024, “The Impact of Repealing the Centers for Medicare and Medicaid Services Minimum Staffing Rule on Patient Outcomes,” Leonard Davis Institute of Health Economics, https://ldi.upenn.edu/our-work/research-updates/comment-the-impact-of-repealing-the-centers-for-medicare-and-medicaid-services-minimum-staffing-rule-on-patient-outcomes/.
7. Werner and Coe, “The Impact of Repealing the Centers for Medicare and Medicaid Services Minimum Staffing Rule on Patient Outcomes.”
8. Zoe Caplan, “U.S. Older Population Grew from 2010 to 2020 at Fastest Rate since 1880 to 1890,” Census.gov, May 25, 2023, https://www.census.gov/library/stories/2023/05/2020-census-united-states-older-population-grew.html.
9. Werner and Coe, “The Impact of Repealing the Centers for Medicare and Medicaid Services Minimum Staffing Rule on Patient Outcomes.”
10. Patricia K. Tong, “The Effects of California Minimum Nurse Staffing Laws on Nurse Labor and Patient Mortality in Skilled Nursing Facilities,” Health Economics 20, no. 7 (2011): 802–16, https://doi.org/10.1002/hec.1638.
11. Min M. Chen and David C. Grabowski, “Intended and Unintended Consequences of Minimum Staffing Standards for Nursing Homes,” Health Economics 24, no. 7 (2014): 82239, https://doi.org/10.1002/hec.3063.
12. Kathryn Hyer, April Temple, and Christopher E. Johnson, “Florida’s Efforts to Improve Quality of Nursing Home Care through Nurse Staffing Standards, Regulation, and Medicaid Reimbursement,” Journal of Aging & Social Policy 21, no. 4 (2009): 318–37, https://doi.org/10.1080/08959420903166910.
13. John R. Bowblis and Andrew Ghattas, “The Impact of Minimum Quality Standard Regulations on Nursing Home Staffing, Quality, and Exit Decisions,” Review of Industrial Organization 50, no. 1 (2017): 43–68, https://www.jstor.org/stable/48722308.
14. Werner. “Minimum Staffing Standards for Long-Term Care Facilities and Medicaid.”