Journal of Law and Policy


For decades, the conditions in America’s nursing homes have been the subject of bombshell media reporting, governmental investigations, and public outrage. Longstanding issues—such as chronic staffing shortages and inadequate infection control measures—were laid bare as the COVID-19 pandemic tore through nursing homes, exposing society’s most vulnerable populations—the elderly and the sick—to appalling living conditions. Amid horrifying media reports documenting life inside nursing homes, and in response to mounting public outrage, legislators sprang into action. The most aggressive policy proposed was a direct care ratio, which caps the profits that nursing home owners can extract from facilities by mandating a minimum percentage of revenue that must be spent on direct patient care. This policy has thus far been enacted by just three states. The crisis in America’s nursing homes is the result of systemic failures in the regulation and oversight of the industry. This Note argues that a truly effective response requires swift and comprehensive federal action. This Note calls on Congress to enact a national direct care ratio with a revenue-focused approach, narrowly defining the costs allowed to count toward the minimum spending requirement and closely scrutinizing submitted costs. The pandemic made clear that the issues in America’s nursing homes are a national problem that require a national solution.