The Nursing Home
That Isn’t There
For decades, millions of families have shared the same unspoken plan: “when the time comes, she’ll go to a nursing home.” Since 2020, more than 400 facilities have permanently closed and over 100,000 beds have disappeared from the American care system. The plan has a problem nobody is talking about.
It is the most common plan in America for aging parents — so common it barely qualifies as a plan at all. It is more of an assumption, shared across millions of families without ever being examined or verified: when the time comes, when living alone is no longer safe, when care is needed around the clock, she will go to a nursing home. The nursing home will handle it. That is what nursing homes are for.
The assumption is understandable. For most of the twentieth century, it was broadly correct. Nursing homes expanded steadily through the 1980s and 1990s, building capacity alongside the first waves of an aging population. By 2019, there were approximately 15,600 nursing facilities in the United States, with roughly 1.7 million certified beds. Supply was tight in some regions but broadly workable nationally. The plan, however imprecise, had infrastructure behind it.
Then 2020 happened. And the plan’s infrastructure began to disappear.
How an Industry That Was Already Struggling Fell Off a Cliff
The nursing home industry was under pressure before COVID arrived. Medicaid reimbursement rates — which fund the majority of nursing home care in America — had been failing to keep pace with labour costs for years. Thin margins meant thin staffing. Thin staffing meant quality problems. Quality problems meant regulatory scrutiny. The industry was already running on fumes in February 2020.
The pandemic was not a shock the system could absorb. Nursing homes became the most visible and devastating sites of COVID mortality. Families pulled residents. New admissions collapsed. Revenue evaporated while costs — PPE, testing, hazard pay, crisis staffing — exploded. Federal relief funds provided a temporary bridge, but they ended. The underlying economics of nursing home operation had been permanently altered.
What followed was a slow, largely invisible contraction. Facilities didn’t close dramatically — they reduced beds, consolidated wings, merged, or quietly wound down operations. The loss of 210,000 frontline care workers created a staffing crisis that, for many facilities, made restoring full capacity mathematically impossible. By 2023, more than half of all nursing homes in the United States were reporting operating losses. The closures that followed were not surprises. They were arithmetic.
“We are approaching a tipping point where the loss of nursing home beds in certain regions will become effectively irreversible. Once a facility closes and workers disperse, the capacity does not come back — not in rural areas, not in the timeline families need it.”— American Health Care Association policy briefing, 2025
State Rankings: Nursing Home Bed Loss Since 2019
Estimated percentage of certified nursing home bed capacity lost or at severe financial risk, by state.
Based on CMS Nursing Home Compare certification data and AHCA financial distress reporting. Full methodology below.
Losing Beds While Gaining Seniors
The states losing the most beds are often the same states with the fastest-growing senior populations — a collision that creates acute regional care crises.
What Was Supposed to Fill the Gap. What Actually Has.
Every policy discussion about declining nursing home capacity includes a reassuring sentence: the gap will be filled by home care and assisted living. The sentence is not wrong. It is simply incomplete. Both alternatives exist. Both are growing. Neither is growing fast enough, at the price point most families can afford, in the geographies that need them most.
What was supposed to fill it
- —Home and community-based care expansion under Medicaid waivers
- —Assisted living growth absorbing displaced nursing home residents
- —Medicare Advantage long-term care benefits expanding access
- —Technology and telehealth reducing need for facility-based care
- —Family caregivers bridging short-term gaps during transitions
- —Federal workforce investment rebuilding the care labour pipeline
What has actually happened
- →Medicaid home care waitlists in most states now run 2–5 years
- →Assisted living costs average $9,000/month in CT — unaffordable without private pay
- →Medicare Advantage LTC benefits vary widely and remain poorly understood
- →Technology supplements care; it does not replace 24-hour physical presence
- →“Short-term” family bridging regularly becomes a multi-year commitment
- →Direct care worker wages remain below $15/hr in most states
How the Capacity Crisis Unfolded
Key milestones in the decline of U.S. nursing home capacity, 2019–2025.
The Connecticut Picture
Connecticut’s nursing home sector entered the pandemic among the most financially vulnerable in the country — high labour costs, above-average regulatory requirements, and Medicaid reimbursement rates that consistently fell short of operating costs. The state lost a significant number of certified beds between 2020 and 2025, with facilities disproportionately concentrated in urban centres, leaving suburban and rural families with increasingly limited access.
For families in Fairfield County, New Haven, and the Hartford corridor, this is a quality and access crisis as much as a financial one. Private pay families can access assisted living and home care more readily — but facility quality has declined broadly, and the most skilled care professionals remain in short supply regardless of budget.
The plan most families never examined is now the plan that no longer works in large parts of the country.
This is not a prediction about what might happen to the nursing home industry. It is a description of what has already happened. The beds are gone. The facilities are closed. The workers dispersed. And the 73 million Baby Boomers moving through their seventies and eighties will encounter a care system that is materially smaller than the one their parents used — while being significantly larger as a population.
The families who navigate this well are not the ones waiting for a crisis to reveal the gap. They are the ones who looked at the actual supply of care available in their region, compared it to what their parent is likely to need, and built a plan around reality rather than assumption. In most cases, that plan involves high-quality home care — not as a stopgap while waiting for a facility bed, but as the primary model.
The nursing home that was always part of the plan may not be there. The question is whether you find that out now, or at 11pm on a Tuesday when you need an answer immediately.
Plan around what’s actually available.
We help Connecticut families understand what care options genuinely exist in their region — and build a structured plan before a crisis forces improvisation. Our initial consultation is private, unhurried, and carries no obligation.
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Sources & Methodology
Nursing home capacity data: CMS Nursing Home Compare / Care Compare provider certification data (2019–2025). American Health Care Association (AHCA), “Trends in Nursing Facility Financial Performance” annual reports 2023–2025. The 100,000+ bed loss figure represents certified bed reductions across closures, delicensing, and capacity reductions reported to CMS.
Financial distress figures: AHCA, “Nursing Facility Financial Health Survey 2023–2024.” 54% operating-at-loss figure from AHCA national member survey.
Workforce data: PHI National, “Direct Care Workers in the United States: Key Facts 2025.” BLS Occupational Outlook Handbook 2024–2032.
Alternative care costs: Genworth/CareScout Cost of Care Survey 2024. CT DSS Medicaid waiver waitlist data, 2025. MedPAC annual report on home health and nursing home access.
Note on state estimates: State bed loss percentages are directional estimates based on CMS provider-of-services trend data and AHCA state-level financial distress reporting. Full current data available at data.cms.gov.
This piece is for informational purposes only and does not constitute medical, legal, or financial advice.