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.
Each dot is a state. X-axis = Medicaid rate/day. Y-axis = CMS Overall Five-Star rating. States that invest more in Medicaid rates tend to have higher-quality nursing facilities. Source: CMS Care Compare July 2026, state Medicaid rate data CY2025.
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.
Medicaid Rate vs. Overall Five-Star Rating
States paying higher Medicaid rates tend to achieve higher overall CMS Five-Star ratings. The correlation isn't perfect — state regulation, workforce availability, and facility ownership matter too — but funding is the strongest lever states control.
Rate vs. Staffing (HPRD)
Rate vs. Staff Turnover
Rate vs. RN Hours
Rate vs. Falls Rate
🔑 Key Finding: Staffing Stars Track Directly with Funding
The CMS Staffing Star rating shows the strongest correlation with Medicaid rates of any quality domain. States paying above $350/day average 3.5 staffing stars. States paying below $250/day average 2.7 staffing stars. This is intuitive: when Medicaid pays enough to hire and retain staff, facilities staff at higher levels.
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 A (Boise, 108-bed) | $7.39/day | $53.57/day | 13.8% | $1,060,000 |
| SNF B (Moscow, 70-bed) | $7.39/day | $49.58/day | 14.9% | $850,000 |
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 A — Real-Time Margin Collapse
108-bed facility in Boise. 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.
Three Idaho Facilities — Real Financial Data
Monthly financial performance from Vena accounting system. No estimates. No projections. Real numbers.
SNF A — Urban (Boise)
108 beds · Ada County · 63.5% Medicaid
Margin collapsing
SNF B — Small City (Moscow)
70 beds · Latah County · Moderate Medicaid
Negative months appearing
SNF C — Rural (Grangeville)
60 beds · Idaho County · Rural tier
Volatile, thin margins
The Pattern Is Clear
All three facilities — urban, small-city, and rural — show the same trajectory: margins compressing toward zero.
SNF A (108-bed, Boise)
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 B (70-bed, Moscow)
Hit negative EBITDAR in May 2026 (-$9,476). Cost from audited CMS cost report: $349/day. Idaho Medicaid pays: $259/day. Gap: $90/day = $1.18M/year lost on Medicaid. Rural facility with 79% occupancy, 65% Medicaid. Capital costs: $49.58/day — property formula pays $7.39 (14.9% coverage). Contract LPN wages at $75/hr vs employee $54 = $100K/yr wasted on agency premium.
SNF C (60-bed, Grangeville)
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 Idaho 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
Replace the 1985 property base and RUG-III case-mix with a 5-component PDPM-based rate system. 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 90% 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 — Three Real Idaho Facilities
All data from audited CMS-2540 cost reports (CY2025) and Vena financial reporting. The rate floor ($333/day = 90% of statewide median cost) governs all three facilities — the safety net works.
SNF A — Shaw Mountain (108-bed, Boise, Urban)
| Metric | Current | Reformed | Change |
|---|---|---|---|
| Medicaid Rate | $259/day | $333/day | +$74 (+28.6%) |
| Actual Cost PPD | $373.21/day (CMS cost report) | -$114 shortfall | |
| Capital Reimbursement | $7.39/day | $35.00/day | +$27.61 (+374%) |
| Cost Coverage | 69.4% | 89.3% | +19.9 pts |
| Net After Assessment | — | — | +$1.39M/yr |
SNF B — Aspen Park (70-bed, Moscow, Rural)
| Metric | Current | Reformed | Change |
|---|---|---|---|
| Medicaid Rate | $259/day | $333/day | +$74 (+28.6%) |
| Actual Cost PPD | $348.59/day (CMS cost report) | -$90 shortfall | |
| Capital Reimbursement | $7.39/day | $35.00/day | +$27.61 (+374%) |
| Cost Coverage | 74.3% | 95.5% | +21.2 pts |
| Net After Assessment | — | — | +$841K/yr |
SNF C — Grangeville (60-bed, Rural + Sole Community)
| Metric | Current | Reformed | Change |
|---|---|---|---|
| Medicaid Rate | $259/day | $333/day | +$74 (+28.6%) |
| Estimated Cost PPD | ~$335/day (Vena estimate, no cost report) | -$76 shortfall | |
| Geographic Bonus | None | +10% (Rural + Sole Comm.) | Highest tier |
| Cost Coverage | ~77% | ~99% | +22 pts |
| Net After Assessment | — | — | +$737K/yr |
Combined Impact: Three Facilities
Total net annual benefit: +$2.97M/year across 238 beds. That’s $12,479 per bed per year in additional funding — enough to hire staff, fix buildings, and keep doors open. All three facilities reach 89–99% cost coverage, up from 69–77%.
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 A 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