James Mathews: U.S. nursing homes face stormy waters amid staffing challenges and an aging population

Readers of a certain age may   recall Sebastian Junger’s book  A Perfect Storm, which describes the last voyage of the Andrea Gail, a Massachusetts swordfishing boat. In October 1991, the boat encountered a violent storm in the North Atlantic Ocean and was lost with all hands. The storm was borne of three converging meteorological conditions: the remains of Hurricane Grace, a coastal Canadian nor’easter and a warm weather system moving in from the Gulf Stream, creating a storm characterized as “perfect” in its destructive energy.  

The idea of a perfect storm risked becoming a cliché from common use at the time. But it aptly describes the impending crisis Medicare beneficiaries face around nursing home care. Policymakers should take note. 

Nursing home staffing: The target of the storm   

During my tenure at the Medicare Payment Advisory Commission (MedPAC), I led an effort aimed at overhauling Medicare’s value-based purchasing program (VBP) for skilled nursing facilities (SNFs).^a Through that work, I became convinced that nursing facility staffing has a strong positive correlation with patient outcomes and quality of care.  

The health services research literature has conclusively shown that delivering high-quality care and better outcomes depends on staffing (including ratios of nurses to patients, and   staff retention), informing MedPAC’s support for including staffing measures in the SNF VBP.^b   

CMS includes staffing measures in the SNF star ratings system (weighted equally with inspections and quality measures), and the agency includes information on staffing on the Nursing Home Compare website (medicare.gov/care-compare). When I have had occasion to help friends and family find a nursing home, I look first and foremost at staffing. 

It was perhaps unsurprising then that CMS proposed and finalized nursing home minimum staffing requirements in 2024.^c Beginning in 2024, SNFs would be required to maintain minimum ratios of nursing hours per resident day and to have a registered nurse on-site 24 hours per day, seven days per week. At this point, the conditions portending a perfect storm began to come together. 

Storm condition 1: The standards 

CMS, recognizing the magnitude of what it was requiring the sector to do, implemented the requirements with a three-year phase-in (five years for rural facilities) and an exemption process for facilities located in areas with tight nursing labor markets. Despite these measures, the reaction from the nursing home sector was energetic, culminating in a U.S. District Court decision vacating the CMS rule.^d The rule was subsequently retracted in a Dec. 3 final rule by the current administration.^e Thus, the first condition of this perfect storm was created. 

The decision is understandable. The relationship between nursing facility staffing and quality of care may be compelling, but it is arguably patently unfair to require nursing homes to hire people who simply aren’t there to be hired. It is hard, often thankless work, but essential to care for an aging population. Finding and retaining people to do these jobs, and do them well, can seem like a Sisyphean task. 

Storm condition 2: Supply 

This brings us to the second sentinel event in December. Following the tragic shooting of two National Guard members posted to Washington DC, President Trump announced a further   tightening of the June 19 travel ban affecting 19 countries. In November, Trump had ended the processing of immigration paperwork and noted the potential for expanding the ban to more than 30 additional countries. This is relevant because, while 15% of the U.S. population is foreign-born, immigrants make up roughly a quarter of the long-term care workforce and can exceed 40% of the workforce for some disciplines in some parts of the country.^f These circumstances mean that a perhaps unintended consequence of tightening legal immigration will be to further constrain the nursing homes’ ability to hire and retain staff.  Thus, supply became the second condition of the perfect storm. 

Storm condition 3: Demand 

This third condition is rapidly building: Within the next few years, the last of the baby boomers (me included) will age into Medicare, while the first baby boomers to enter Medicare will be entering their 80s. The Health Resources and Services Administration projects that demand for long-term care workers will grow by 39% between 2022 and 2037.⁷ Such estimates track projections not only of the number of older adults living in institutional settings, which could double in the next 10 years, but also of the future demand for nursing homes.⁸  

These rising conditions mean Medicare faces a perfect storm on the post-acute care horizon (without even touching on the implications of millions of beneficiaries who are dually eligible for both Medicare and Medicaid who will truly need to call nursing facilities their “homes”).   

Home-based care is often touted as a solution to the problems facing institutional care, but care at home still requires someone to provide that care, and despite the best hopes for AI, we are likely to find that it will fall short.  

Policymakers need to shore up the levees — the storm is nigh upon us.  

Footnotes

a.  See Medicare Payment Advisory Commission, Report to the Congress: Medicare and the health care delivery system, June 2021.
b.  Medicare Payment Advisory Commission, 2022, Comment letter on CMS’s proposed rule on skilled nursing facilities for FY 2023, June 8.
c.  CMS, “Medicare and Medicaid programs: Minimum staffing standards for long-term care facilities and Medicaid institutional payment transparency reporting,” final rule, Federal Register, May 10, 2024.
d. “American Health Care Association, et al., v. Robert F. Kennedy, et al., U.S. District Court for the Northern District of Texas Amarillo Division,” April 7, 2025.
e. CMS, “Medicare and Medicaid programs: Repeal of minimum staffing standards for long-term care facilities,” final rule, Federal Register, Dec. 3, 2025.
f.  Jun, H., and Grabowski, D.C., “Nursing home staffing: Share of immigrant certified nursing assistants grew as US-born staff numbers fell, 2010-21,” Health Affairs, January 2024; and Chidambaram, P., and Pillai, D., “What role do immigrants play in the direct long-term care workforce?” KFF, April 2, 2025.
g.  HRSA National Center for Health Workforce Analysis, “Long-term services and support: demand projections, 2022-2037,” fact sheet, November 2024.
h.  Shuman, T., “How will America’s ‘Silver Tsunami’ impact demand for nursing homes?” seniorliving.org, Nov. 17, 2025.