America's Nursing Facilities Are in Crisis
Medicaid pays for 62% of all nursing home residents nationally — and in most states, it doesn't cover the cost of care.
The Funding Gap Is a Quality Gap
Medicaid is the dominant payer for nursing facility care in America. When states underfund Medicaid rates, facilities can't hire enough staff, can't maintain buildings, and can't provide quality care. The data shows a clear pattern: states that pay more get better care.
Average Quality by Medicaid Rate Tier
10 Lowest-Paying vs. 10 Highest-Paying States
MO, ID, LA, CA, NH
WV, OR, HI, ND, DE, AK
Source: CMS Care Compare July 2026, state Medicaid rate data CY2025. Tiers calculated from actual Medicaid NF per diem rates (not swing-bed). Staffing stars show the strongest correlation with funding of any quality domain.
The Workforce Crisis
National average CNA turnover: 45.8%. In states paying the lowest Medicaid rates, CNA wages can't compete with retail and fast food. Workers leave for jobs that pay more and demand less.
Average total nursing HPRD nationally: 3.86
CMS proposes a minimum of 3.48 — many underfunded states can't even hit that floor.
The Access Crisis
An estimated 2,500+ nursing facilities have closed since 2020. Rural facilities close first, forcing elderly residents to relocate 50-100+ miles from family. Once a facility closes, the infrastructure doesn't come back.
Displaced Medicaid residents end up in hospitals at 3-5× the daily cost — still on Medicaid, but now far more expensive.
The Formula Problem
Many states use decades-old rate formulas that haven't kept up with inflation, labor costs, or modern care standards. Idaho's property reimbursement base was set in 1985. Some states still use patient classification systems that CMS abandoned in 2019.
💡 The Opportunity: Federal Matching Funds
The Federal Medical Assistance Percentage (FMAP) means every dollar a state invests in Medicaid generates $1–$3+ in federal matching funds. Most states also have provider assessment programs (47 of 50) that generate additional revenue at no cost to taxpayers. Several states are leaving billions in federal funds on the table by maintaining artificially low rates.
50-State Medicaid Nursing Facility Dashboard
Compare Medicaid rates, quality metrics, staffing, and methodology across all states.
| State ↕ | Rate/Day ↕ | Rank ↕ | Overall ★ ↕ | Staffing ★ ↕ | Total HPRD ↕ | RN HPRD ↕ | Turnover ↕ | Falls % ↕ | Methodology ↕ | Facilities ↕ |
|---|
Sources: CMS Care Compare July 2026, MACPAC 2019 Medicaid NF Base Payments (inflation-adjusted); MN Rate Study 2025; state-specific sources. Click any column header to sort. Idaho highlighted in red.
Does Funding Drive Quality?
Visual analysis of the relationship between Medicaid reimbursement and nursing facility quality outcomes.
The Evidence: Bottom 5 vs. Top 5
5 Lowest-Paying States
| Nevada | $243 | 3.3★ | 4.30 HPRD |
| Illinois | $243 | 2.1★ | 3.44 HPRD |
| Oklahoma | $245 | 2.6★ | 3.78 HPRD |
| Texas | $252 | 1.9★ | 3.39 HPRD |
| South Carolina | $254 | 3.0★ | 3.83 HPRD |
5 Highest-Paying States
| Oregon | $568 | 3.8★ | 5.04 HPRD |
| Hawaii | $571 | 4.5★ | 4.99 HPRD |
| North Dakota | $586 | 4.2★ | 4.42 HPRD |
| Delaware | $601 | 4.0★ | 4.35 HPRD |
| Alaska | $800 | 4.5★ | 6.69 HPRD |
The 5 lowest-paying average 2.58 staffing stars and 3.75 HPRD.
That's 63% more staffing star points — because they can afford to hire people.
Idaho: A State in Crisis
Idaho ranks 46th nationally in Medicaid nursing facility rates — the lowest in the Intermountain West.
Idaho vs. Neighbors
Idaho has the highest FMAP (best federal leverage) in the region — and the lowest Medicaid rate. Every neighbor gets less federal help and still pays more.
The $9.24 Problem
Idaho's property reimbursement formula uses a base rate of $9.24 per patient day, set in statute in 1985. For buildings older than 30 years, this produces $7.39/day in property reimbursement. Here's what that means for real facilities:
| Facility | Formula Pays | Actual Capital Cost | Coverage | Annual Shortfall |
|---|---|---|---|---|
| SNF 1 (Urban, 108-bed) | $7.39/day | $53.57/day | 13.8% | $1,060,000 |
| SNF 2 (Rural, 68-bed) | $7.39/day | ~$45/day | ~16% | $820,000 |
| SNF 3 (Rural, 60-bed, Sole Comm.) | $7.39/day | $58.68/day | 12.6% | $633,000 |
| SNF 4 (Rural, 40-bed) | $7.39/day | $11.40/day | 64.8% | $35,000 |
Combined: $1.9M/year in unrecovered capital costs across just two facilities. Scale that to 80 facilities statewide.
"Idaho is reimbursing building costs using a formula from the year Back to the Future came out."
SNF 1 — Real-Time Margin Collapse
108-bed urban facility. 92% occupied. 63.5% Medicaid. One of the strongest operating profiles in Idaho — and margins are collapsing.
Idaho Facility Closures Since 2020
Good Samaritan Society — Boise Village
127 beds — Closed May 20, 2021
64 years in operation. CMS terminated Medicare/Medicaid contract after repeated compliance failures. Residents relocated. Building converted to affordable senior housing (Sycamore Commons, opened June 2026).
One of only two nursing homes nationally to have its CMS contract terminated in 2021.
Caribou Memorial Living Center — Soda Springs
~30 beds — Closed May 1, 2021
County-owned, attached to Caribou Memorial Hospital. $2M annual shortfall. Medicaid covered ~25% of actual costs. Nearest alternative: 30 miles over a mountain pass.
"CMH Living Center lost an average of $75,480 per resident last year. Regulatory agencies require standards of care and staffing levels that are not supported by reimbursement."
Net loss since 2020: 2 facilities, ~157 beds. Active facilities: 80. Certified beds: 6,099.
Idaho Quality Profile
Idaho's total turnover rate of 50.3% is the 9th highest nationally — above the 45.8% national average. High turnover directly correlates with lower Medicaid rates: facilities can't pay competitive wages, so staff leaves.
Four Idaho Facilities — Real Financial Data
Monthly financial performance from validated internal accounting systems. No estimates. No projections. Real numbers.
SNF 1 — Urban
108 beds · Ada County · 63.5% Medicaid
Margin collapsing
SNF 2 — Rural
68 beds · Rural · 66.5% Medicaid
Negative months appearing
SNF 3 — Rural (Sole Community)
60 beds · Rural county · Rural tier
Volatile, thin margins
SNF 4 — Rural (90% Medicaid)
40 beds · Rural tier · 89.9% Medicaid
Most rate-dependent facility
The Pattern Is Clear
All four facilities — urban, small-city, and rural — show the same trajectory: margins compressing toward zero.
SNF 1 (108-bed, Urban)
EBITDAR margin went from 24.2% (Jan 2024) to 0.3% (Mar 2026). This is a well-run, 92% occupied, urban facility with the strongest operating profile in the state. Cost from audited CMS cost report: $373/day. Idaho Medicaid pays: $259/day. Gap: $114/day = $2.6M/year lost on Medicaid.
SNF 2 (68-bed, Rural)
1.8% annual EBITDA margin on $7.96M revenue — operating on a razor's edge. Cost per day: ~$361/day. Idaho Medicaid pays: $259/day. Gap: $102/day = $1.47M/year lost on Medicaid. 87% occupied, 66.5% Medicaid, 4-star CMS quality. Revenue declining 7.1% into 2026. Reformed rate with rural adjustment: $370/day = profitable on Medicaid for the first time.
SNF 3 (60-bed, Rural)
Rural facility with volatile margins swinging from -3.4% to +35.1%. Already hit negative EBITDAR in June 2024 (-$19,273). December 2025: $11K EBITDAR on $447K revenue — 2.6% margin. Only SNF in Rural county — if it closes, 60 beds gone and nearest alternative is 90+ miles away. Qualifies for Rural + Sole Community (+10%) under the reform. Rate floor provides the most protection here: $29.36/day above formula.
The Idaho Nursing Facility Sustainability & Quality Act
A comprehensive reform package for the 2027 Idaho Legislative Session.
Six Reforms
A. Modern Rate Formula
Add eight targeted enhancements to the existing cost-based system. Property modernization, rate floor ($352), rural and access supplements, quality incentive program, rate cut protections. Transparent, published formulas. Annual mandatory rebasing.
B. Unlock Federal Funds
Increase provider assessment from 3.5% to 5.5% (below 6% federal cap). 47 states already do this. Generates $66.5M in federal match at Idaho's 70% FMAP.
C. Quality Incentives
100-point quality scorecard. $15/day bonus for scores 80+. $30/day for 90+. 15 measures across clinical outcomes, staffing, satisfaction, and compliance.
D. Rate Floor
No facility rate below 95% of statewide median cost. Mid-year cuts require fiscal emergency + 180-day notice + access study + public hearings + JFAC review.
E. Workforce Pipeline
CNA scholarships, LPN-to-RN tuition assistance, wage floor support, retention bonuses. Funded by 10%+ of sustainability fund. Target: 500-800 new CNAs/year.
F. Transparency
Annual rate calendar. Public hearings. Published methodology and data. Annual report to Legislature. No more holiday-weekend rate cuts.
What Changes — Four Real Idaho Facilities
All data from audited CMS-2540 cost reports (CY2025) and validated financial reporting. Rate floor at 95% of statewide median ($352/day) with geographic adjustments applied on top. Rural buildings are profitable on Medicaid under this structure — the safety net works.
SNF 1 (108-bed, Urban)
| Metric | Current | Reformed | Change |
|---|---|---|---|
| Medicaid Rate | $259/day | $352/day (floor) | +$93 (+35.9%) |
| Actual Cost PPD | $373/day (CMS cost report) | -$21 gap (94.4% coverage) | |
| Quality Pathway | — | Tier 2 (+$15) = $367 | 98.4% coverage |
| Net After Assessment | — | — | +$1.83M/yr |
SNF 2 (68-bed, Rural)
| Metric | Current | Reformed | Change |
|---|---|---|---|
| Medicaid Rate | $259/day | $370/day (floor + rural 5%) | +$111 (+42.9%) |
| Cost PPD | ~$361/day (validated financials) | +$9/day = profitable | |
| Cost Coverage | 71.7% | 102.5% | +30.8 pts |
| Net After Assessment | — | — | +$1.44M/yr |
SNF 3 (60-bed, Rural + Sole Community)
| Metric | Current | Reformed | Change |
|---|---|---|---|
| Medicaid Rate | $259/day | $387/day (floor + rural 5% + sole 5%) | +$128 (+49.4%) |
| Actual Cost PPD | $381/day (CMS cost report) | +$6/day margin = profitable | |
| Geographic Bonus | None | +10% (Rural + Sole Comm.) | Highest tier |
| Cost Coverage | 68.1% | 101.6% | +33.5 pts |
| Net After Assessment | — | — | +$1.46M/yr |
SNF 4 (40-bed, Rural, 90% Medicaid)
| Metric | Current | Reformed | Change |
|---|---|---|---|
| Medicaid Rate | $259/day | $370/day (floor + rural 5%) | +$111 (+42.9%) |
| Actual Cost PPD | $343/day (CMS cost report) | +$27/day margin = profitable | |
| Medicaid Census | 89.9% (170 Medicare days/yr) | Most rate-dependent | |
| Cost Coverage | 75.6% | 107.9% | +32.3 pts |
| Net After Assessment | — | — | +$1.12M/yr |
Combined Impact: Four Facilities
Total net annual benefit: +$5.85M/year across 276 beds. Three rural buildings are profitable on Medicaid under this structure. The urban building reaches break-even with quality investment. Average cost coverage goes from 71% to 101%.
3-Year Phase-In
| Phase | Year | What Happens |
|---|---|---|
| Phase 1 | FY 2028 | Assessment → 5.5%. Workforce fund launches. Methodology development begins. Hold-harmless: no rate cuts. |
| Phase 2 | FY 2029 | Component-based methodology goes live. Property base modernized. BAF eliminated. First rate calendar published. |
| Phase 3 | FY 2030 | Quality incentive program fully operational. Scorecards published. Bonus payments begin ($15-30/day). |
The Numbers That Matter
Stats that end arguments. Use them.
$9.24 — Set in 1985
Idaho's property reimbursement base. 41 years old. Produces $7.39/day against $53.57 actual cost. Covers 13.8%.
"Reagan was in his second term. The Space Shuttle Challenger hadn't launched yet."
$2.80 Per Idaho Resident Per Year
Year 1 net state cost: $5.3M ÷ 1.9M residents = $2.80. Unlocks $32M in federal funds. ROI: 233%.
"Name another line item with a 233% return."
CNAs Make Less Than Walmart Greeters
Idaho NF CNA wages: $14-17/hr. Walmart: $15-19/hr. Amazon: $17-21/hr. CNAs change dressings, manage meds, lift patients, comfort dying people — for less than shelf stockers.
69 Cents on the Dollar
SNF 1 cost: $373/day. Idaho Medicaid: $259/day. Shortfall: $114/day × 22,951 Medicaid days = $2.6M/year lost — at the best building in the state.
47 States Already Do This
Provider assessments within the 6% federal safe harbor. Idaho is one of only 3 that don't fully utilize this tool. $45M/year in unclaimed federal funds.
Zero Accountability Today
Current law has no quality scorecard, no workforce pass-through, no annual report, no rate transparency, no rate reduction protections. This bill adds all of them.
Take Action
What you can do to support nursing facility reform in Idaho.
📧 Contact Your Legislator
Find your Idaho state representative and senator at legislature.idaho.gov. Tell them you support the Idaho Nursing Facility Sustainability & Quality Act.
Key message: "I support modernizing Idaho's nursing facility Medicaid rates. At $259/day — 46th nationally — our rates don't cover the cost of care. The reform costs $2.80 per Idaho resident and unlocks $32M in federal funds."
📝 Write a Letter
Handwritten letters from constituents are the most powerful advocacy tool. Share your personal experience with a family member in a nursing facility, or as a healthcare worker.
🏥 Visit Your Local Facility
See the reality firsthand. Ask the administrator about staffing challenges, building maintenance needs, and the impact of Medicaid rates on their operations.
📊 Share This Data
Share this website with anyone who cares about nursing facility quality in Idaho: medicaidreform.org
Idaho Health Care Association
The IHCA represents 80+ nursing facilities, 6,200+ licensed beds, and 9,400+ healthcare workers across Idaho.
Contact: Lindsay Likes, Director of Government Affairs
(208) 343-9735 · 13945 W. Wainwright Drive, Suite 101, Boise, Idaho 83713
Idaho Reform Campaign: ihcareform.org
Rate Methodology Correlations
Analysis of 51 jurisdictions. Data from CMS Care Compare July 2026, WPS GHA CY2025 Medicaid rates, BLS.
Rates by Region
Idaho ($259/day) falls below every regional average, including the Southeast.
Rate Methodology Drives Funding Level
States with modern rate-setting methodologies pay significantly more. Idaho uses cost-based, the lowest-paying methodology type.
Higher Rates = Better Outcomes
States in the top third of Medicaid rates have higher quality ratings, lower staff turnover, and more nursing hours per resident.
Correlation across 51 jurisdictions. States that pay more have 10% higher quality scores, 9% less staff turnover, and 13% more nursing hours per resident day.
Idaho: Western Costs, Southern Rates
Idaho operates in a Western labor market with cost-of-living pressures comparable to its neighbors. But its Medicaid rate ranks with the Southeast.