On behalf of the Idaho Health Care Association and our member facilities serving more than 8,000 residents across the state, I am writing to request a meeting with you and your policy team to discuss a comprehensive proposal to modernize Idaho's Medicaid nursing facility reimbursement system.
As you know, Idaho currently ranks 46th nationally in Medicaid nursing facility reimbursement at approximately $259 per day — the lowest rate in the Intermountain West. Our neighboring states reimburse significantly more: Montana at $314, Oregon at $322, and Washington at $356 per day. Idaho's property rate component has not been meaningfully updated since its establishment in 1985 at $9.24 per day, and the state continues to use the RUG-III patient classification system that the Centers for Medicare & Medicaid Services itself abandoned in 2019.
IHCA has spent more than two years developing the Idaho Nursing Facility Sustainability & Quality Act, a detailed legislative proposal that would transition Idaho to the Patient-Driven Payment Model (PDPM) used by Medicare, update property rate methodology, and establish a provider assessment at 5.5% — well within the federal safe harbor of 6%. We have modeled this proposal to generate a net first-year cost to the state of approximately $5.3 million while leveraging Idaho's 70% Federal Medical Assistance Percentage to draw more than $2.33 in federal funds for every $1 of state investment.
We have prepared a complete technical administration guide detailing the methodology, fiscal projections, transition timeline, and quality accountability measures. We believe this document will demonstrate that our proposal is fiscally responsible, administratively workable, and closely aligned with the Department's own commitment to quality outcomes and sustainable programming.
Our intent in requesting this meeting is collaborative. We want to share our analysis, hear the Department's perspective, and identify areas where we can work together to strengthen the proposal before it enters the legislative process. We firmly believe that a partnership approach between the provider community and DHW will produce the best outcome for Idaho's residents and taxpayers.
We are available at your convenience during September or October 2026 and would welcome the opportunity to present to whatever combination of your leadership team you feel is appropriate. We anticipate the initial briefing would require approximately 60 to 90 minutes.
Please feel free to have your office contact me directly at (208) 343-9735 or via email to schedule a convenient date. I am also happy to provide any preliminary materials your team would like to review in advance of our meeting.
Thank you for your continued partnership in serving Idaho's most vulnerable residents. We look forward to this conversation.
We are writing on behalf of the Idaho Health Care Association to respectfully request an informal pre-consultation meeting with your office regarding a proposed State Plan Amendment that the State of Idaho may submit in connection with nursing facility Medicaid reimbursement reform legislation anticipated during the 2027 legislative session.
IHCA represents the majority of Idaho's skilled nursing facilities, assisted living communities, and intermediate care facilities. Over the past two years, we have developed a comprehensive legislative proposal — the Idaho Nursing Facility Sustainability & Quality Act — that would modernize Idaho's nursing facility reimbursement methodology and establish a provider assessment to fund enhanced rates.
We are seeking informal guidance from your office on two specific elements of the proposal:
1. Provider Assessment Structure. The proposal would establish a provider assessment on nursing facility beds at a rate of 5.5%, which falls within the 6% federal safe harbor established under 42 U.S.C. § 1396b(w). The assessment would be applied as a uniform, broad-based tax on licensed bed days across all participating Medicaid nursing facilities. We would welcome your informal perspective on the assessment structure and any design elements that would facilitate a smooth approval process.
2. Rate Methodology Alignment with PDPM. The proposed rate methodology transitions Idaho from the legacy RUG-III patient classification system — which CMS retired from the Medicare program in 2019 — to a methodology aligned with the Patient-Driven Payment Model (PDPM). The proposal uses PDPM case-mix categories and acuity-adjusted payment tiers while maintaining state-specific cost-based components consistent with Medicaid upper payment limit requirements. We would appreciate any informal feedback on how this methodology aligns with current CMS expectations for State Plan Amendments.
We want to emphasize that we are not requesting formal review or binding guidance at this stage. We understand that any State Plan Amendment would be formally submitted by the State of Idaho through the established process. Our goal in this pre-consultation is to ensure that the proposal we bring to the Idaho Legislature and the Department of Health & Welfare is designed from the outset to align with federal requirements, minimizing the need for revisions during the formal review process.
We have prepared a detailed technical document that includes the complete rate methodology, provider assessment structure, fiscal projections, and transition timeline. We would be pleased to share this document with your team in advance of any meeting.
We are available to travel to your Seattle office at your convenience, or we would be equally glad to conduct this discussion via videoconference. We anticipate the briefing would require approximately 60 minutes.
Thank you for your consideration. We look forward to working collaboratively with Region 10 as Idaho takes this important step toward sustainable nursing facility care.
On behalf of the Idaho Health Care Association — representing more than 140 skilled nursing facilities, assisted living communities, and residential care providers across all 44 counties — we are writing to request a brief meeting with you or your senior policy staff to discuss a legislative proposal that addresses one of rural Idaho's most pressing workforce and healthcare access challenges.
Governor, more than ten nursing facilities have closed their doors in Idaho since 2020. For rural communities, each closure means families must travel hours to visit a parent or spouse in care — or, too often, that an aging Idahoan must leave the community where they lived their entire life. These closures are not the result of poor management. They are the predictable consequence of a Medicaid reimbursement system that has fallen dangerously behind.
Idaho ranks 46th in the nation in Medicaid nursing facility reimbursement at approximately $259 per day. Every one of our Intermountain West neighbors pays substantially more: Montana at $314, Oregon at $322, and Washington at $356. Our facilities compete for certified nursing assistants against employers like Walmart and Amazon that now offer $15 to $19 per hour, while our Medicaid rates allow us to pay only $14 to $17. The workforce math simply does not work.
The Idaho Nursing Facility Sustainability & Quality Act is a fiscally conservative proposal that addresses this crisis through a three-part approach: modernizing Idaho's outdated rate methodology, establishing a provider assessment at 5.5% — well within the federal safe harbor — and leveraging Idaho's 70% Federal Medical Assistance Percentage to maximize the federal return on every state dollar invested.
The numbers tell a compelling story. For a net state investment of approximately $5.3 million — roughly $2.80 per Idaho resident — the proposal generates more than $2.33 in federal matching funds for every state dollar, creating a total investment in Idaho's nursing facility infrastructure that stabilizes an industry employing thousands of Idahoans in every corner of the state. Forty-seven other states already use some form of provider assessment for this purpose. Idaho is among the last three that do not.
This proposal aligns directly with your administration's priorities: protecting rural communities, creating jobs, maximizing the return on taxpayer dollars through federal matching, and ensuring that Idaho's seniors can age in their home communities with dignity.
We would welcome the opportunity to present a 30-minute briefing at your convenience. We are also happy to provide materials in advance for your team's review.
Thank you for your longstanding commitment to Idaho's seniors and rural communities. We look forward to continuing this important conversation.
The Idaho Health Care Association is preparing to support introduction of the Idaho Nursing Facility Sustainability & Quality Act during the 2027 legislative session. Before this legislation is formally introduced and a fiscal note is requested, we would like to proactively present our independent fiscal analysis to your office so that the Division of Financial Management has complete information as early as possible in the process.
We have developed a comprehensive fiscal model that addresses the General Fund impact, provider assessment revenue projections, federal matching fund calculations under Idaho's current 70% FMAP, and a five-year cost trajectory. Our analysis projects a net first-year General Fund cost of approximately $5.3 million, with the provider assessment generating sufficient revenue to offset the majority of the gross rate increase through federal match leverage.
Our model includes the following components that we believe will be directly relevant to your fiscal note analysis:
• Detailed rate methodology calculations and per-diem impact projections
• Provider assessment revenue estimates at the proposed 5.5% rate
• Federal match calculations under current and projected FMAP rates
• Sensitivity analysis under varying census and acuity assumptions
• Five-year fiscal trajectory with inflation and caseload growth factors
• Comparison data from the 47 states currently operating similar programs
We recognize that DFM will conduct its own independent analysis, and we welcome that scrutiny. Our goal in this briefing is not to influence your conclusions but to ensure your team has access to the most complete data set available, including provider-level financial data that may not be readily accessible through other channels.
We are available at your convenience and would anticipate the briefing requiring approximately 45 to 60 minutes. Robert Vande Merwe, IHCA Executive Director, and Luke Malek, IHCA Policy Director, would present. We are happy to provide our complete fiscal model in advance.
Thank you for your consideration. We look forward to a productive conversation.
I am writing to request that the Legislative Services Office draft legislation based on the enclosed proposal for the Idaho Nursing Facility Sustainability & Quality Act, to be introduced during the First Regular Session of the 69th Idaho Legislature.
The enclosed package includes a complete draft of the proposed legislation, organized into the following sections:
• Title 56, Chapter 1: Amendments establishing the Idaho Nursing Facility Sustainability & Quality Act, including findings, purpose, and definitions
• Rate Methodology: Transition from RUG-III to a Patient-Driven Payment Model (PDPM) aligned classification system
• Provider Assessment: Establishment of a 5.5% provider assessment on nursing facility beds, within the federal 6% safe harbor
• Nursing Facility Sustainability Trust Fund: Creation of a dedicated fund to receive assessment revenue and federal matching funds
• Quality Accountability: Performance metrics, reporting requirements, and rate adjustments tied to quality outcomes
• Implementation Timeline: Phased transition schedule with Department of Health & Welfare rulemaking authority
• Appropriation: First-year General Fund appropriation of approximately $5.3 million
A supporting technical document with fiscal analysis, rate modeling, and comparative state data is also enclosed for LSO's reference in preparing the fiscal note.
I have worked closely with the Idaho Health Care Association in developing this proposal. Robert Vande Merwe, IHCA Executive Director, and Luke Malek, IHCA Policy Director, are available to answer any technical questions your drafting team may have. Mr. Malek can be reached at (208) 343-9735.
I would appreciate the opportunity to review the initial draft before finalization. Please contact my office to arrange a review meeting at your convenience.
Thank you for your attention to this request.
Dear [First Name],
I hope this message finds you well. As you may know, I've recently joined the Idaho Health Care Association as Policy Director, and I'm reaching out about an issue I believe deserves thoughtful, bipartisan attention from the Legislature next session.
I served with many of you in the Idaho House from 2012 to 2018, and I know firsthand that the best legislation happens when members from both sides of the aisle work together on problems that affect real people in every district. The issue I want to bring to your attention is exactly that kind of problem.
Idaho's nursing facility Medicaid reimbursement system is in crisis. We rank 46th in the nation at $259 per day — dead last in the Intermountain West. More than ten facilities have closed since 2020, and the communities they served often have nowhere else to turn. The property rate component of Idaho's formula hasn't been meaningfully updated since 1985. We're still using a patient classification system that CMS abandoned in 2019. And our facilities are losing CNAs to Walmart because they simply cannot compete on wages.
IHCA has spent two years developing the Idaho Nursing Facility Sustainability & Quality Act — a comprehensive, data-driven reform package modeled on what 47 other states already do. Here's the short version:
• Modernizes rate methodology to align with the Medicare PDPM system
• Establishes a 5.5% provider assessment (within the 6% federal safe harbor)
• Leverages Idaho's 70% FMAP to generate $2.33 in federal funds for every $1 of state investment
• Net first-year state cost: approximately $5.3 million — about $2.80 per Idahoan
• Includes quality accountability measures and full transparency requirements
This isn't a partisan issue. It's a math problem, a workforce problem, and a rural access problem. Forty-seven states have already solved it this way. Idaho shouldn't be one of the last three.
I'd welcome the chance to sit down with you — in person or by phone — to walk through the proposal and the supporting data. No pressure, no hard sell. If the data persuades you, I'd be honored to have your leadership on this as a sponsor or co-sponsor. If it doesn't, I'd value your candid feedback on how to make it stronger.
I've attached a two-page summary. The complete technical package runs to over 100 pages and is available whenever you'd like to see it.
Would you have 30 minutes in the next few weeks? Happy to come to you.
Warm regards,
Luke Malek, Esq.
Policy Director
Idaho Health Care Association
(208) 343-9735
Former Member, Idaho House of Representatives, District 4 (2012–2018)
On behalf of AARP Idaho and our more than 230,000 members across the state, I am writing to express our strong support for the Idaho Nursing Facility Sustainability & Quality Act (H.B. ____).
AARP's mission is to empower people to choose how they live as they age. For many Idaho families, that choice increasingly involves a nursing facility — and the ability to access quality nursing facility care close to home is being eroded by a Medicaid reimbursement system that has not kept pace with the cost of providing that care.
Idaho ranks 46th nationally in Medicaid nursing facility reimbursement. More than ten facilities have closed since 2020. For the families we serve, these closures are devastating. When a nursing facility closes in a rural community, it often means a husband or wife must drive hours to visit their spouse, or an aging parent must leave the community where they raised their family. The emotional and financial toll on families is immeasurable.
The Sustainability & Quality Act takes a responsible, proven approach used by 47 other states. It modernizes an outdated payment system, leverages federal matching funds to maximize the return on state investment, and includes accountability measures to ensure that increased funding translates into improved resident care.
For Idaho's seniors and their families, this bill is about one fundamental thing: the ability to receive quality care in their home community. We urge the committee to give this legislation the thoughtful consideration it deserves.
AARP Idaho stands ready to work with the Legislature, the Department of Health & Welfare, and the Idaho Health Care Association to advance this critical reform.
The Idaho Hospital Association writes in support of the Idaho Nursing Facility Sustainability & Quality Act (H.B. ____). While this legislation addresses nursing facility reimbursement, its impact extends directly to Idaho's hospitals and the patients we serve.
Idaho's hospitals are experiencing a growing crisis in patient throughput driven in large part by the inability to discharge patients to appropriate post-acute care settings. When nursing facilities close or reduce capacity — as more than ten have done since 2020 — hospital emergency departments and inpatient units bear the consequences. Patients who are medically ready for discharge remain in acute care beds because there is no nursing facility bed available, particularly in rural communities.
This "boarding" problem is expensive. An acute care hospital bed costs three to five times more per day than a nursing facility bed. When patients who need post-acute care occupy acute beds, those beds are unavailable for patients arriving in our emergency departments with genuine acute care needs. The downstream effects include longer emergency department wait times, ambulance diversion, and worse outcomes for patients across the care continuum.
Stabilizing Idaho's nursing facility sector through the Sustainability & Quality Act will directly benefit hospitals by restoring appropriate discharge options, reducing emergency department boarding, and ensuring that each patient receives care in the most appropriate — and most cost-effective — setting.
From a fiscal perspective, every dollar invested in stabilizing nursing facility capacity avoids multiples of that dollar in unnecessary acute care spending — much of which is also borne by the Medicaid program. This legislation is not just sound health policy. It is sound fiscal policy for the entire continuum of care.
IHA urges the committee's favorable consideration of this important legislation.
The Idaho Medical Association, representing physicians across all specialties and practice settings in Idaho, writes in support of the Idaho Nursing Facility Sustainability & Quality Act (H.B. ____).
As physicians, we see firsthand the clinical consequences of Idaho's nursing facility capacity crisis. When patients in our care need skilled nursing, rehabilitation, or long-term residential care, the options available to them have diminished steadily as facilities close or reduce capacity. More than ten nursing facilities have closed in Idaho since 2020, and many of those that remain operate under severe staffing constraints driven by Medicaid reimbursement rates that rank 46th nationally.
The clinical implications are significant. Patients discharged from hospitals without access to appropriate post-acute nursing care face higher rates of readmission, medication errors, falls, and other complications. Physicians practicing in rural Idaho communities report increasing difficulty arranging timely placement for patients who need skilled nursing services. The result is fragmented care, interrupted treatment plans, and worse clinical outcomes.
The Sustainability & Quality Act proposes to modernize Idaho's nursing facility reimbursement by transitioning to the Patient-Driven Payment Model — the same evidence-based classification system that the Centers for Medicare & Medicaid Services adopted for Medicare in 2019. This alignment promotes clinical consistency, supports appropriate acuity-based staffing, and creates financial incentives for the kind of quality-focused care that produces the best patient outcomes.
From a physician perspective, a stable, adequately funded nursing facility sector is essential infrastructure. It is as critical to patient care as hospital capacity and physician supply. We urge the committee to advance this legislation.
The Idaho Commission on Aging writes to express support for the Idaho Nursing Facility Sustainability & Quality Act (H.B. ____) and to share the perspective of Idaho's aging services network on the urgent need for nursing facility reimbursement reform.
Idaho's population aged 65 and older is the fastest-growing demographic segment in the state. Over the next decade, the number of Idahoans who will need some form of long-term care services will increase dramatically. At the same time, the infrastructure to provide that care — particularly in skilled nursing facilities — is contracting. More than ten nursing facilities have closed since 2020, disproportionately in the rural and frontier communities where Idaho's seniors are most concentrated.
The Commission regularly hears from seniors and their families who face impossible choices: accept care in a facility hours from home, rely on family caregivers who are themselves aging, or forego care altogether. In communities that have lost their nursing facility, the entire fabric of senior support is weakened. Meals on Wheels routes lose volunteers. Respite care disappears. Community health resources diminish. The nursing facility is often the anchor institution for senior services in a small town, and its loss cascades across the community.
The Sustainability & Quality Act addresses the root cause of this erosion: Medicaid reimbursement rates that rank 46th nationally and cannot sustain operations, particularly in Idaho's highest-cost rural markets. The proposal's approach — modernizing rate methodology, leveraging federal matching funds, and building in quality accountability — is exactly the kind of responsible, evidence-based reform that serves Idaho's aging population.
We urge the Legislature to advance this critical legislation and stand ready to assist in any way the committee finds helpful.
As the Area Agency on Aging for Region [__], serving [counties/communities], I am writing to express strong support for the Idaho Nursing Facility Sustainability & Quality Act (H.B. ____).
Our agency works every day with Idaho seniors and their families navigating the long-term care system. We see the direct community-level impact of nursing facility closures and capacity reductions. When a facility closes in one of our service communities, it creates a ripple effect that extends far beyond the residents and families directly affected.
Nursing facilities serve as critical community infrastructure in rural Idaho. They are often among the largest employers in small towns. They provide the safety net that allows families to keep aging parents close to home. They anchor a network of related services — home health, therapy, adult day programs — that depend on the facility's presence. When the facility leaves, much of this support network collapses.
Idaho's Medicaid reimbursement rates — 46th nationally and the lowest in the Intermountain West — are the primary driver of these closures. The Sustainability & Quality Act provides a responsible, proven solution that 47 other states have already adopted. For a net state cost of approximately $2.80 per Idaho resident, this legislation protects communities, preserves jobs, and ensures that our seniors can access the care they need without leaving their home regions.
We urge the committee to pass this legislation and preserve the community-based infrastructure that Idaho's seniors depend upon.
The Idaho Council on Developmental Disabilities writes in support of the Idaho Nursing Facility Sustainability & Quality Act (H.B. ____), with particular attention to its impact on intermediate care facility (ICF) residents with intellectual and developmental disabilities.
Idaho's ICF/IDD facilities serve some of the state's most vulnerable residents — individuals who depend on 24-hour supervised care, structured programming, and specialized staffing. These facilities face the same Medicaid reimbursement crisis as Idaho's nursing homes, and in many cases, the staffing challenges are even more acute. Direct support professionals in ICF settings require specialized training and consistent relationships with the individuals they serve. The chronic underfunding created by rates that rank 46th nationally makes it nearly impossible to recruit, train, and retain these essential caregivers.
When an ICF facility reduces capacity or closes, the impact on its residents is profound. Individuals with developmental disabilities are often acutely sensitive to disruptions in routine, environment, and relationships. Placement transitions — particularly emergency placements resulting from facility closures — can cause significant behavioral and emotional regression that takes months or years to address.
The Sustainability & Quality Act's rate modernization and quality accountability framework will directly benefit ICF residents by stabilizing the facilities that serve them and creating the financial foundation for appropriate staffing levels and program quality. We commend the bill's inclusion of ICF facilities in the provider assessment and rate enhancement structure.
The Council urges the committee to advance this legislation as a critical step in protecting Idaho's most vulnerable residents.
My name is [Your Name], and I am a resident of [City, Idaho] in your district. I am writing because my [mother/father/spouse/family member] is a resident at [Facility Name] in [City], and I am deeply concerned about the future of nursing facility care in our community.
[Share a brief personal story: When did your family member enter the facility? What care do they receive? What has your experience been? Have you seen the impact of staffing shortages? Example: "My mother moved to Sunny Acres in 2023 after her stroke. The staff there are wonderful people who care deeply about their residents, but I can see they are stretched thin. Some weeks, I notice there simply aren't enough aides to help everyone who needs assistance at mealtimes."]
I've learned that Idaho ranks 46th in the nation in what Medicaid pays nursing facilities — just $259 per day, the lowest rate in our region. Montana, Oregon, and Washington all pay significantly more. It's no wonder that more than ten facilities across Idaho have closed since 2020. When I think about what would happen if [Facility Name] closed, it frightens me. The nearest alternative is [distance/city], which would make it nearly impossible for our family to visit regularly.
I understand the Legislature will be considering the Idaho Nursing Facility Sustainability & Quality Act next session. This bill would update the payment system, bring in more federal matching dollars, and help facilities like [Facility Name] keep their doors open and pay their caregivers a fair wage. The net cost to the state would be about $2.80 per Idahoan — a small investment to protect access to care for our most vulnerable neighbors.
I respectfully ask you to support this legislation. For families like mine, it's about knowing that our loved ones can stay in their community, close to the people who love them.
Thank you for your service to our district. I would welcome the opportunity to speak with you about this issue if it would be helpful.
My name is [Your Name], and I work as a [CNA/LPN/RN/dietary aide/activity director] at [Facility Name] in [City, Idaho]. I have worked in nursing facility care for [number] years, and I am writing to ask for your support of the Idaho Nursing Facility Sustainability & Quality Act.
I chose this work because I care deeply about the residents I serve. They become like family to me. But I won't pretend it's easy. I earn approximately [$__] per hour — and I know that the Walmart down the road starts at $15 to $19 per hour for work that doesn't require certification, doesn't involve 12-hour shifts, and doesn't carry the physical and emotional demands of caring for vulnerable people.
I stay because I love my residents. But I've watched many of my coworkers leave for those other jobs. When they leave, those of us who remain have to care for more residents with fewer hands. That means less time for the small things that matter most — sitting with a resident who is frightened, helping someone eat at their own pace, or just being present when a family member needs reassurance.
[Optional: Share a specific experience — a time when short staffing affected resident care or your own well-being. Keep it factual and protect resident privacy.]
I understand that Idaho's Medicaid rates are 46th in the nation and that the Legislature will have an opportunity to change that. The Sustainability & Quality Act would help facilities pay competitive wages so they can hire and keep the caregivers our residents need and deserve. It would bring in more federal dollars to support these increases, and it would hold facilities accountable for using the funds to improve care.
I'm not asking for anything extraordinary. I'm asking for a system that values the work we do enough to sustain it. Please support this legislation.
I am the administrator of [Facility Name] in [City, Idaho], a [XX]-bed [skilled nursing facility / assisted living community / ICF] that has served this community for [XX] years. I am writing to respectfully request your support for the Idaho Nursing Facility Sustainability & Quality Act in the upcoming legislative session.
Let me share what the numbers look like from the ground. Our facility employs approximately [XX] people — making us one of the [largest / significant] employers in [City/County]. Approximately [XX%] of our residents are covered by Medicaid, which reimburses us at approximately $259 per day. Our actual cost of care is approximately [$___] per day. That gap — roughly [$___] per resident per day — is not sustainable.
Our most urgent challenge is workforce. We compete for certified nursing assistants against employers that can offer $15 to $19 per hour for entry-level positions. Our Medicaid rates allow us to pay $14 to $17 per hour for work that requires state certification, involves physically demanding 12-hour shifts, and carries enormous emotional weight. We currently have [XX] open CNA positions. Every vacancy means more work for the remaining staff and less individualized attention for our residents.
The property and infrastructure challenges are equally stark. Idaho's property rate base dates to 1985, and the reimbursement does not come close to covering the cost of maintaining aging physical plants, much less meeting modern life safety and infection control standards. We have deferred approximately [$___] in capital improvements because the funding simply isn't there.
The Sustainability & Quality Act would modernize Idaho's rate methodology, establish a provider assessment that leverages $2.33 in federal funds for every $1 of state investment, and create quality accountability measures. As an administrator, I welcome accountability — we want to demonstrate that increased funding produces better outcomes. This bill gives us both the resources and the framework to do exactly that.
I would welcome the opportunity to host you at our facility so you can see firsthand the challenges we face and the care our staff provides every day despite those challenges. Please don't hesitate to contact me.
For IHCA Member Facility Administrators and Activity Directors
Generate a minimum of 5 personalized letters per facility — from family members, employees, and administrators — to the state legislators representing each facility's district. Personal, handwritten or individually typed letters are far more effective than form letters or petitions.
Letters should be mailed or emailed by [target date — approximately 2-3 weeks before the legislative session opens] so that legislators receive them before session begins.
In 2020, a nursing home in a small Idaho town closed its doors for the last time. The staff had done everything they could. The administrator had cut every cost that could be cut without compromising safety. But when the math doesn't work, dedication alone can't keep the lights on.
That community lost more than a building. Families lost the ability to visit their parents and grandparents without a two-hour drive. The town lost one of its largest employers. And dozens of vulnerable residents were uprooted from the place they called home.
Since then, more than ten Idaho nursing facilities have closed. And unless the Legislature acts, more will follow.
The root cause is not mismanagement or greed. It is a Medicaid reimbursement system that has fallen dangerously behind. Idaho currently ranks 46th in the nation in what it pays nursing facilities to care for Medicaid residents — approximately $259 per day. To put that in perspective, every one of our neighbors pays more. Montana pays $314. Oregon pays $322. Washington pays $356. Idaho's property rate component — the portion of the payment that covers building maintenance, equipment, and physical infrastructure — has not been meaningfully updated since it was set at $9.24 per day in 1985.
Think about that. The state's formula for what it costs to maintain a nursing facility building is based on 1985 dollars. Reagan was in his second term. The Berlin Wall was still standing. A gallon of gas cost $1.09.
Meanwhile, Idaho's nursing facilities are trying to recruit and retain certified nursing assistants — the frontline caregivers who help our parents and grandparents eat, bathe, dress, and maintain their dignity — at $14 to $17 per hour. Walmart starts at $15 to $19. Amazon starts higher. No certification required, no 12-hour shifts, no heartbreak when the resident you've cared for every day for two years passes away.
The Idaho Health Care Association has spent more than two years developing a solution. The Idaho Nursing Facility Sustainability & Quality Act would do three things. First, it would modernize the state's rate methodology to align with the Patient-Driven Payment Model that Medicare adopted in 2019 — the same system CMS uses to classify patients and determine payment nationally. Second, it would establish a provider assessment at 5.5 percent, within the federal safe harbor of 6 percent, creating a dedicated funding stream. Third, it would leverage Idaho's 70 percent Federal Medical Assistance Percentage to generate $2.33 in federal matching funds for every $1 the state invests.
The net first-year cost to Idaho's General Fund would be approximately $5.3 million. That works out to $2.80 per Idaho resident. For context, the state budgeted approximately $5.1 billion in General Fund spending for fiscal year 2026. We are talking about one-tenth of one percent of the state budget to stabilize an entire sector of healthcare infrastructure.
And Idaho is not pioneering anything here. Forty-seven states already use some form of provider assessment to fund nursing facility Medicaid rates. Idaho is one of only three that do not. We are not asking the state to experiment. We are asking it to catch up.
The bill includes robust accountability measures. Facilities that receive enhanced rates would be required to meet quality performance standards, report workforce data, and demonstrate that increased funding is producing better outcomes. This is not a blank check. It is an investment with built-in accountability.
I have spent more than two decades in long-term care — first as a nursing facility administrator and now leading IHCA. I have never seen the industry under this level of stress. The facilities that remain open are running on the commitment of their staff and the resilience of their communities. But commitment and resilience cannot substitute for sustainable funding forever.
The 2027 legislative session presents an opportunity to fix this — not with a partisan agenda, but with a data-driven, fiscally responsible proposal modeled on what nearly every other state has already done. Idaho's nursing facility residents, their families, and the caregivers who serve them deserve nothing less.
I run a nursing home in [City], Idaho. We have [XX] beds, [XX] employees, and [XX] residents who call this place home. Most of our residents are from this community. They taught in our schools, farmed our land, ran our businesses, and raised the families who still live here. They deserve to spend their final years surrounded by the people and the place they love.
That's getting harder to guarantee.
Idaho ranks 46th in the nation in what Medicaid pays for nursing facility care — $259 per day. Our actual cost of providing that care is closer to [$___]. Every Medicaid resident we serve costs us money. We don't turn anyone away, because that's not who we are. But the math is brutal.
The biggest challenge is finding and keeping staff. I'm competing for CNAs against employers that don't require certification and offer better pay. My Medicaid rates let me pay $14 to $17 an hour. The distribution center forty-five minutes away pays $18. I've lost good, caring people — not because they stopped caring, but because they have families to feed.
When a rural nursing home closes, it doesn't just affect the residents. It affects the entire community. We're one of the biggest employers in [City/County]. Our payroll circulates through local businesses. Our facility anchors home health services, therapy providers, and other care resources. Take away the nursing home, and you take away a piece of the community's foundation.
The Idaho Legislature will consider the Nursing Facility Sustainability & Quality Act next session. It's a straightforward proposal: modernize our outdated payment system, use a provider assessment to draw more federal matching dollars into Idaho, and hold facilities accountable for spending the money on quality care. Forty-seven other states already do this.
The cost to Idaho taxpayers? About $2.80 per person per year. For that investment, we keep our doors open, pay our staff fairly, and keep our residents in their communities.
I'm not asking for a handout. I'm asking for a system that works. Please contact your state legislators and ask them to support this bill. Our community's nursing home — and communities like ours across Idaho — are counting on it.
My [mother/father/spouse] lives at [Facility Name] in [City]. The people who care for [him/her] every day are some of the most dedicated, compassionate workers I've ever known. They deserve better than what Idaho is giving them.
Idaho ranks 46th in the nation in Medicaid nursing facility reimbursement — the lowest rate in the Intermountain West. That means the caregivers who help my [mother/father/spouse] eat, dress, and maintain [his/her] dignity earn $14 to $17 an hour, while Walmart pays $15 to $19 for stocking shelves. More than ten nursing facilities have closed in Idaho since 2020 because they simply can't make the numbers work.
The Idaho Nursing Facility Sustainability & Quality Act, expected to be introduced in the 2027 legislative session, would fix this. It would modernize Idaho's payment system, bring in more federal matching funds, and stabilize the facilities that families like mine depend on — for about $2.80 per Idaho resident. Forty-seven other states already do this.
I urge our legislators to support this common-sense reform. For families with loved ones in nursing facility care, this isn't a political issue. It's personal.
[Your Name]
[City, Idaho]
BOISE, Idaho — [Representative/Senator _____] today introduced the Idaho Nursing Facility Sustainability & Quality Act (H.B. ____), bipartisan legislation to modernize Idaho's nursing facility Medicaid reimbursement system, leverage federal matching funds, and stabilize care for the more than 8,000 Idahoans who reside in skilled nursing facilities, assisted living communities, and intermediate care facilities.
Idaho currently ranks 46th nationally in Medicaid nursing facility reimbursement at approximately $259 per day — the lowest rate in the Intermountain West. More than ten nursing facilities have closed since 2020, and the state continues to use a patient classification system abandoned by the federal government in 2019.
The legislation would transition Idaho to a modern rate methodology aligned with the Patient-Driven Payment Model (PDPM) used by Medicare, update a property rate base that has remained essentially unchanged since 1985, and establish a 5.5% provider assessment — within the 6% federal safe harbor — to create a sustainable funding mechanism.
"Idaho is one of only three states in the nation that does not use a provider assessment to fund nursing facility Medicaid rates," said the bill's sponsor. "This legislation catches us up to what 47 other states already do, and it does so in a way that maximizes the return on taxpayer investment through federal matching funds."
"Our facilities are the safety net for Idaho's most vulnerable residents — seniors, individuals with disabilities, and people recovering from acute illness and injury. This legislation gives them a fighting chance to keep their doors open, pay their workers fairly, and provide the quality of care that Idahoans deserve."
— Riley Sessions, President, IHCA Board of Directors
The bill leverages Idaho's 70% Federal Medical Assistance Percentage (FMAP) to generate approximately $2.33 in federal matching funds for every $1 of state investment. The net first-year General Fund cost is estimated at approximately $5.3 million — roughly $2.80 per Idaho resident.
"We've spent two years building this proposal with one question in mind: what can Idaho do today to ensure that nursing facility care is available, affordable, and high-quality for the next generation of Idahoans? This bill is the answer. It's conservative, it's accountable, and it works."
— Robert Vande Merwe, Executive Director, Idaho Health Care Association
The legislation includes quality accountability measures requiring facilities that receive enhanced rates to meet performance standards, report workforce investment data, and demonstrate measurable improvement in care outcomes.
"The methodology in this bill is aligned with federal standards, the assessment structure is within established safe harbors, and the accountability framework is as rigorous as anything we've seen nationally. We built it to withstand scrutiny because this issue is too important for anything less."
— Luke Malek, Esq., Policy Director, Idaho Health Care Association
The bill has been endorsed by a coalition of organizations including [coalition members — update as endorsements are confirmed].
The bill has been referred to the [House Health & Welfare Committee / relevant committee]. A committee hearing has not yet been scheduled.
For any media interview, public appearance, or legislative testimony