NASI Warns U.S. Long‑Term Care Faces Steep Staffing Cliff — and Offers a Blueprint to Fix It

The nation’s long-term care system is heading toward a deeper staffing crisis unless policymakers adopt a coordinated plan to recruit, train, and retain workers at scale, according to a new analysis from the National Academy of Social Insurance (NASI).

The nonpartisan group projects the sector will need roughly 1.2 million additional direct care workers by 2030 to keep pace with an aging population. At the same time, federal staffing minimums finalized in 2024 are coming due, and many facilities remain far from meeting them.

By the numbers: a widening gap

NASI’s 2025 Long-Term Care Workforce Survey paints a stark picture: 72% of nursing homes reported turnover above 50% last year. Certified nursing assistants (CNAs), who provide most hands-on care, earned an average of $16.50 an hour — below basic living wage estimates in the majority of states, the report notes.

The demand side is swelling. About 10,000 Americans turn 65 every day, a trend that will stretch through the end of the decade. Facilities already report limiting admissions due to staff shortages, which pushes more older adults into hospitals or home settings that may lack adequate support, according to industry reports.

Mandates without money?

The Centers for Medicare & Medicaid Services (CMS) in 2024 set new minimum staffing standards for nursing homes, aiming for 3.48 hours of nursing care per resident per day, including specific thresholds for registered nurses and nurse aides. Implementation is being phased in, with longer timelines for rural facilities and hardship exemptions available.

But compliance remains a hurdle. NASI’s analysis suggests only a fraction of facilities consistently meet the new thresholds today, citing ongoing labor shortages and funding constraints. Medicaid — the program that pays for most nursing home days — has not kept up with inflation in many states, operators say, complicating efforts to raise wages and stabilize schedules. Reliance on temporary agency staff has increased sharply since the pandemic, pushing labor costs even higher without improving retention, the brief adds.

A blueprint for rebuilding the workforce

NASI outlines a national workforce strategy that combines near-term relief with longer-term pipeline building. Proposals include targeted wage supports tied to quality metrics, expanded training and apprenticeship programs in partnership with community colleges, and streamlined immigration pathways for experienced caregivers — a critical lever given that roughly one in four direct care workers in the U.S. is foreign-born.

Technology has a role, too. The brief points to remote monitoring, smarter scheduling tools, and documentation support to reduce administrative burden. But it cautions against viewing tech as a substitute for people. The goal, it says, is to enable staff to focus on relationship-based care, not to reduce headcount.

“The workforce behind long-term care is the backbone of our aging society, yet it’s crumbling under neglect,” said NASI Senior Fellow Dr. Elena Ramirez, a lead author of the report. “Without a meaningful federal commitment by 2026, we’ll see a cascade of closures and suffering that no amount of regulation can fix.”

Mark Thompson, a NASI policy analyst and co-author, said immigration changes could be part of the near-term fix if paired with strong training and protections. “Visa expansions could bring in needed caregivers quickly, but we have to ensure pathways that prevent exploitation and support career growth,” he said.

Funding, equity, and what comes next

NASI estimates a federal investment on the order of $10 billion annually could stabilize the workforce and prevent avoidable hospitalizations — costs that ultimately reverberate through Medicare and state budgets. Early pilots, including federal training and retention grants announced in 2025, are a start but not enough on their own, the brief argues.

The report also underscores equity concerns: women make up the vast majority of long-term care workers, and people of color are overrepresented in low-wage roles. Raising pay, creating real advancement ladders, and improving safety and scheduling are essential not just to recruitment, NASI says, but to retention.

Legal and operational headwinds persist. Some industry groups have pushed back on the federal staffing rule, warning it could accelerate closures in rural areas without parallel funding support. State initiatives tying reimbursement to staffing and quality are emerging but vary widely.

For now, the brief calls for Congress to fold long-term care workforce funding into upcoming budget negotiations and for states to align Medicaid policy with hiring goals. It also urges providers to double down on data-driven scheduling and retention practices that have shown early success in cutting turnover.

The stakes are clear, NASI concludes: without a stronger workforce, access will shrink, quality will slip, and costs will shift elsewhere in the system. With it, the sector can meet the demographic wave — and treat care work like the skilled, essential labor it is.