[House Report 118-745]
[From the U.S. Government Publishing Office]
118th Congress } { Rept. 118-745
HOUSE OF REPRESENTATIVES
2d Session } { Part 1
======================================================================
PROTECTING AMERICAN SENIORS' ACCESS TO CARE ACT
_______
November 18, 2024.--Ordered to be printed
_______
Mr. Smith of Missouri, from the Committee on Ways and Means, submitted
the following
R E P O R T
[To accompany H.R. 7513]
The Committee on Ways and Means, to whom was referred the
bill (H.R. 7513) to prohibit the Secretary of Health and Human
Services from finalizing a proposed rule regarding minimum
staffing for nursing facilities, and to establish an advisory
panel on the skilled nursing facility workforce, having
considered the same, reports favorably thereon with amendments
and recommends that the bill as amended do pass.
CONTENTS
Page
I. SUMMARY AND BACKGROUND........................................... 2
A. Background and Need for Legislation................. 2
B. Legislative History................................. 4
Background.......................................... 4
Committee Hearings.................................. 4
Committee Action.................................... 4
C. Designated Hearing.................................. 4
II. EXPLANATION OF THE BILL.......................................... 4
A. Reasons for Change.................................. 4
B. Explanation of Provisions........................... 4
C. Effective Date...................................... 4
III. VOTES OF THE COMMITTEE........................................... 5
IV. BUDGET EFFECTS OF THE BILL....................................... 5
A. Committee Estimate of Budgetary Effects............. 5
B. Statement Regarding New Budget Authority and Tax
Expenditures Budget Authority...................... 5
V. COST ESTIMATE PREPARED BY THE CONGRESSIONAL BUDGET OFFICE........ 5
VI. OTHER MATTERS TO BE DISCUSSED UNDER THE RULES OF THE HOUSE....... 6
A. Committee Oversight Findings and Recommendations.... 6
B. Statement of General Performance Goals and
Objectives......................................... 6
C. Information Relating to Unfunded Mandates........... 6
D. Congressional Earmarks, Limited Tax Benefits, and
Limited Tariff Benefits............................ 6
E. Duplication of Federal Programs..................... 6
The amendments are as follows:
Strike all after the enacting clause and insert the
following:
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Protecting American Seniors' Access to
Care Act''.
SEC. 2. PROHIBITION ON FINALIZING PROPOSED STAFFING RULE.
The Secretary of Health and Human Services may not finalize,
implement, enforce, or otherwise give effect to the proposed rule
entitled ``Medicare and Medicaid Programs; Minimum Staffing Standards
for Long-Term Care Facilities and Medicaid Institutional Payment
Transparency Reporting'' published by the Department of Health and
Human Services on September 6, 2023 (88 Fed. Reg. 61352-61429) and may
not promulgate any substantially similar rule.
Amend the title so as to read:
A bill to prohibit the Secretary of Health and Human
Services from finalizing a proposed rule regarding minimum
staffing for skilled nursing facilities and nursing facilities.
I. SUMMARY AND BACKGROUND
A. Background and Need for Legislation
On August 29, 2023, the Centers for Medicare & Medicaid
Services (CMS) released--apparently inadvertently--a report the
agency commissioned to assess potential mandatory minimum
staffing levels for Skilled Nursing Facilities (SNFs).\1\ CMS
had previously suggested this report would inform coming action
related to nursing home staffing requirements. While the
report, dated June 2023, found that higher staffing levels
generally correlate with higher quality, the report cautioned,
``there is no obvious plateau at which quality and safety are
maximized or ``cliff'' below which quality and safety steeply
decline.''\2\ Despite the fact that the CMS-commissioned report
could not identify a staffing rate at which quality and safety
are maximized, CMS nevertheless continued with a significant
regulatory action to create a new federal staffing standard.
---------------------------------------------------------------------------
\1\https://www.cms.gov/files/document/nursing-home-staffing-study-
final-report-appendix-june-2023.pdf.
\2\https://www.cms.gov/files/document/nursing-home-staffing-study-
final-report-appendix-june-2023.pdf.
---------------------------------------------------------------------------
On September 1, 2023, CMS issued a proposed rule,
``Medicare and Medicaid Programs: Minimum Staffing Standards
for Long-Term Care Facilities and Medicaid Institutional
Payment Transparency Reporting.''\3\ Among other things, the
rule proposed three new SNF staffing requirements that exceed
the existing statutory staffing requirements found in Section
1819 of the Social Security Act, which requires SNFs to provide
24-hour licensed nursing service, including the use of an RN at
least seven days weekly for eight consecutive hours daily.\4\
Specifically, under the proposed rule, SNFs would be required
to have a Registered Nurse (RN) onsite, provide at least 0.55
hours per resident day (HRPD) of care from an RN, and provide
at least 2.45 HRPD of care from a Nurse Aide (NA).
---------------------------------------------------------------------------
\3\https://www.federalregister.gov/documents/2023/09/06/2023-18781/
medicare-and-medicaid-programs-minimum-staffing-standards-for-long-
term-care-facilities-and-medicaid.
\4\Section 1819(b)(4)(C) of the Social Security Act.
---------------------------------------------------------------------------
The Committee is concerned that the proposed rule, if
finalized, would have a deleterious effect on Medicare
beneficiaries' access to SNF care. Specifically, one study
examined Payroll-Based Journal data submitted to CMS by
Medicare-certified nursing homes, estimating that Medicare-
certified SNFs would need to hire an estimated 102,154
additional full-time employees, including 22,077 RNs and 80,077
NAs.\5\ Additionally, the Committee is concerned that this
mandate would be burdensome and unreasonable, given the
considerable evidence of serious and ongoing staff shortages in
the nursing home industry. For example, in February 2024, the
Department of Health and Human Services Office of Inspector
General published a report that emphasized the persistent staff
shortages in the nursing home field, saying, ``one of the
biggest and most difficult challenges was the shortage of
qualified staff.''\6\
---------------------------------------------------------------------------
\5\https://www.ahcancal.org/News-and-Communications/FactSheets/
FactSheets/CLA%20
Staffing%20Mandate%20Analysis%20-%20September%202023.pdf.
\6\https://oig.hhs.gov/documents/evaluation/9808/OEI-02-20-
00492.pdf.
---------------------------------------------------------------------------
During the period after the proposed rule's publication,
Committee heard concerns from a variety of stakeholders about
the lack of qualified staff available to ensure SNFs meet the
mandate, if finalized. For example, according to the leading
national association representing nonprofit nursing homes,
``there are simply no people to hire--especially nurses. The
proposed rule requires that nursing homes hire additional
staff. But where are they coming from?''\7\ State-level
nonprofit nursing home associations echoed these concerns,
saying the CMS proposed rule would ``further exacerbate the
healthcare workforce shortages, place undue financial burdens
on care facilities, and potentially decrease access to care . .
.''\8\ Another emphasized ``there are simply not enough
workers,'' and a third stated, ``Adding impossible mandates
will make accessing care more difficult for older Americans and
their families as providers will have to limit admissions.''\9\
Especially concerning to the Committee is that more than
280,000 nursing home residents could be affected by census
reductions performed to meet the mandated provider-to-staff
ratios.\10\
---------------------------------------------------------------------------
\7\https://leadingage.org/leadingage-reax-on-biden-administrations-
proposed-staffing-mandates/.
\8\https://leadingage.org/leadingage-state-executives-on-impact-of-
cms-proposed-staffing-mandate/.
\9\Id.
\10\https://www.ahcancal.org/News-and-Communications/Press-
Releases/Pages/New-Analysis-Finds-FederalStaffing-Mandate-Would-
Require-100,000-Additional-Nurses-and-Nurses'-Aides,-Cost-$6-8-Billion-
Pe.aspx.
---------------------------------------------------------------------------
On February 29, 2024, more than 1,000 organizations sent a
letter to Chairman Smith and Ranking Member Neal saying, ``this
mandate will neither improve care nor address the workforce
crisis . . . Now is simply not the time to implement a nursing
home staffing rule that could severely impact the health care
continuum and access for patients to critical care.''\11\
Signatories of the letter included non-profit nursing homes, as
well as national and state-level associations representing non-
profit, rural, and religious-affiliated nursing homes.
---------------------------------------------------------------------------
\11\https://leadingage.org/wp-content/uploads/2024/02/FINAL-
2.28.24-Protecting-Rural-Seniors-Access-to-Care-Act-H.R.-5796-WM-Mark-
Up-Letter.pdf.
---------------------------------------------------------------------------
Based on the proposed rule's potential for serious harm,
namely jeopardizing seniors' access to SNF services,
congressional action is needed to prohibit the finalization and
enforcement of the proposal.
B. Legislative History
Background
H.R. 7513 was introduced on March 1, 2024, and was referred
to the Committee on Ways and Means and the Committee on Energy
and Commerce.
Committee Hearings
The Committee on Ways and Means held the following
hearing(s) concerning the policy in H.R. 7513:
On March 28, 2023, the Committee on Ways and Means held a
hearing titled, ``President Biden's Fiscal Year 2024 Budget
Request with Health and Human Services Secretary Becerra'' to
discuss the President's fiscal year 2024 budget request and
related proposals including the proposal to implement staffing
ratio mandates on nursing homes.
Committee Action
The Committee on Ways and Means marked up H.R. 7513, the
Protecting America's Seniors' Access to Care Act, on March 6,
2024, and favorably reported the bill, as amended, to the House
of Representatives (with quorum being present).
C. Designated Hearing
Pursuant to clause 3(c)(6) of rule XIII, the following
hearing was used to develop and consider H.R. 7513:
On March 28, 2023, the Committee on Ways and Means held a
hearing titled, ``President Biden's Fiscal Year 2024 Budget
Request with Health and Human Services Secretary Becerra.''
II. EXPLANATION OF THE BILL
A. Reasons for Change
Absent congressional action, the Secretary of Health and
Human Services, acting through CMS, would be allowed to
finalize the proposed staffing mandate. As the mandate would
likely have deleterious effects on America's seniors, Congress
must act to prohibit finalization, implementation, and
enforcement of the proposed rule.
B. Explanation of Provisions
Section 1: Short title
The title of the bill is the Protecting American Seniors
Access to Care Act.
Section 2: Prohibition on Finalizing Proposed Staffing Rule
Prohibits the Secretary of Health and Human Services from
finalizing, implementing, enforcing, or otherwise giving effect
to the CMS staffing mandate proposed rule.
C. Effective Date
The bill would become effective upon enactment.
III. VOTES OF THE COMMITTEE
In compliance with the Rules of the House of
Representatives, the following statement is made concerning the
vote of the Committee on Ways and Means during the markup
consideration of H.R. 7513, the ``Protecting America's Seniors'
Access to Care Act,'' on March 6, 2024.
H.R. 7513 was ordered favorably reported to the House of
Representatives as amended by a roll call vote of 26 yeas to 17
nays (with a quorum being present). The vote was as follows:
----------------------------------------------------------------------------------------------------------------
Representative Yea Nay Present Representative Yea Nay Present
----------------------------------------------------------------------------------------------------------------
Mr. Smith (MO)..................... X ...... ......... Mr. Neal............. ...... X .........
Mr. Buchanan....................... X ...... ......... Mr. Doggett.......... ...... X .........
Mr. Smith (NE)..................... X ...... ......... Mr. Thompson......... ...... X .........
Mr. Kelly.......................... X ...... ......... Mr. Larson........... ...... X .........
Mr. Schweikert..................... X ...... ......... Mr. Blumenauer....... ...... X .........
Mr. LaHood......................... X ...... ......... Mr. Pascrell......... ...... X .........
Dr. Wenstrup....................... X ...... ......... Mr. Davis............ ...... X .........
Mr. Arrington...................... X ...... ......... Ms. Sanchez.......... ...... X .........
Dr. Ferguson....................... X ...... ......... Ms. Sewell........... X ...... .........
Mr. Estes.......................... X ...... ......... Ms. DelBene.......... ...... X .........
Mr. Smucker........................ X ...... ......... Ms. Chu.............. ...... X .........
Mr. Hern........................... X ...... ......... Ms. Moore............ ...... X .........
Ms. Miller......................... X ...... ......... Mr. Kildee........... ...... X .........
Dr. Murphy......................... X ...... ......... Mr. Beyer............ ...... X .........
Mr. Kustoff........................ X ...... ......... Mr. Evans............ ...... X .........
Mr. Fitzpatrick.................... X ...... ......... Mr. Schneider........ ...... X .........
Mr. Steube......................... X ...... ......... Mr. Panetta.......... ...... X .........
Ms. Tenney......................... X ...... ......... Mr. Gomez............ ...... X .........
Mrs. Fischbach..................... X ...... .........
Mr. Moore.......................... X ...... .........
Mrs. Steel......................... X ...... .........
Ms. Van Duyne...................... X ...... .........
Mr. Feenstra....................... X ...... .........
Ms. Malliotakis.................... X ...... .........
Mr. Carey.......................... X ...... .........
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IV. BUDGET EFFECTS OF THE BILL
A. Committee Estimate of Budgetary Effects
With respect to clause 3(d) of rule XIII of the Rules of
the House of Representatives, a cost estimate provided by the
Congressional Budget Office pursuant to section 402 of the
Congressional Budget Act of 1974 was not made available to the
Committee in time for the filing of this report.
B. Statement Regarding New Budget Authority and Tax Expenditures Budget
Authority
In compliance with clause 3(c)(2) of rule XIII of the Rules
of the House of Representatives, the Committee states that the
bill involved no new or increased budget authority. The
Committee states further that the bill involves no new or
increased tax expenditures.
V. COST ESTIMATE PREPARED BY THE CONGRESSIONAL BUDGET OFFICE
With respect to the requirements of clause 3(c)(2) of rule
XIII of the Rules of the House of Representatives and section
308(a) of the Congressional Budget Act of 1974 and with respect
to requirements of clause (3)(c)(3) of rule XIII of the Rules
of the House of Representatives and section 402 of the
Congressional Budget Act of 1974, the Committee has requested
but not received a cost estimate for this bill from the
Director of Congressional Budget Office. The Chairman of the
Committee shall cause such estimate and statement to be printed
in the Congressional Record upon its receipt by the Committee.
VI. OTHER MATTERS TO BE DISCUSSED UNDER THE RULES OF THE HOUSE
A. Committee Oversight Findings and Recommendations
With respect to clause 3(c)(1) of rule XIII of the Rules of
the House of Representatives, the Committee made findings and
recommendations that are reflected in this report.
B. Statement of General Performance Goals and Objectives
With respect to clause 3(c)(4) of rule XIII of the Rules of
the House of Representatives, the Committee advises that the
bill does not authorize funding, so no statement of general
performance goals and objectives is required.
C. Information Relating to Unfunded Mandates
This information is provided in accordance with section 423
of the Unfunded Mandates Reform Act of 1995 (Pub. L. No. 104-
4).
The Committee has determined that the bill does not contain
Federal mandates on the private sector. The Committee has
determined that the bill does not impose a Federal
intergovernmental mandate on State, local, or tribal
governments.
D. Congressional Earmarks, Limited Tax Benefits, and Limited Tariff
Benefits
With respect to clause 9 of rule XXI of the Rules of the
House of Representatives, the Committee has carefully reviewed
the provisions of the bill, and states that the provisions of
the bill do not contain any congressional earmarks, limited tax
benefits, or limited tariff benefits within the meaning of the
rule.
E. Duplication of Federal Programs
In compliance with clause 3(c)(5) of rule XIII of the Rules
of the House of Representatives, the Committee states that no
provision of the bill establishes or reauthorizes: (1) a
program of the Federal Government known to be duplicative of
another Federal program; (2) a program included in any report
from the Government Accountability Office to Congress pursuant
to section 21 of Public Law 111-139; or (3) a program related
to a program identified in the most recent Catalog of Federal
Domestic Assistance, published pursuant to the Federal Program
Information Act (Pub. L. No. 95-220, as amended by Pub. L. No.
98-169).
[all]