Shifting the Costs of Nursing Home Care

Over 70% of older adults will likely require significant long-term care—for at least 90 days—at some point in their lives. Nursing homes across the United States are at risk of closing or delivering poor quality care due to worsening staff shortages and funding shortfalls in Medicaid, the primary payer for long-term care. The One Big Beautiful Bill Act (OBBBA), signed into law in July 2025, compounds these concerns with approximately $1 trillion in cuts to Medicaid over the next decade. Even though many of the major provisions do not go into effect until 2027 or later, states are already scrambling to find ways to cut spending and budget accordingly. One way that states could do this is through shifting more of the burden of long-term care needs onto families, creating unexpected cost pressures on adult children who may be struggling to make ends meet themselves.

Filial responsibility laws hold adult children financially responsible for their elderly parents’ needs, endorsing a quid pro quo or reciprocal expectation of caregiving. They are a legacy of English “poor laws”, which established the historical foundation for social safety-net programs and the notion that family resources should be exhausted before relying on public benefits. Although England repealed its filial support laws in 1948, these laws are still on the books in over half of the United States. That said, they are rarely enforced, and several states have repealed them. However, states have a history of strategically reviving dormant laws, like pre-Roe abortion restrictions, when it becomes advantageous for them. If filial laws were enforced again, it would be particularly concerning, given that states already require the elderly to spend down their assets to qualify for nursing home care through Medicaid.

As states become increasingly desperate to balance their budgets, there could be renewed interest in filial laws as a mechanism to offset costs.

As long-term care costs continue to steeply rise, nursing homes in states with filial responsibility laws could resort to holding children financially liable for their parents’ care, even with no evidence of wrongdoing. In fact, Reagan-era guidance noted this possibility for state Medicaid programs, and two states have used these laws as a “primary collection tool for nursing homes,” going after family members retroactively to cover costs. Court decisions in Pennsylvania and South Dakota applied filial statutes to hold adult children liable for their parents’ health care debts. As states become increasingly desperate to balance their budgets, there could be renewed interest in filial laws as a mechanism to offset costs.

The OBBBA exacerbates the already steep challenges of how states fund their share of Medicaid costs in several ways. First, it prohibits states from raising provider taxes or creating new taxes to finance Medicaid. Provider taxes, levied on hospitals and nursing homes among others, help fund each state’s share of Medicaid costs.

Second, the OBBBA reduces retroactive coverage from 90 to 30 days, exposing those enrolling in the program to higher costs. Patients and their families often discover their eligibility for Medicaid through a major health care event, with retroactive eligibility helping to cover the bills when they were already eligible, just not enrolled. The average nursing home costs roughly $10,000 per month for a shared room, and even a couple of months could wipe out most Americans’ savings.

Unpaid caregiving in the U.S. is valued at over half a trillion dollars per year, emphasizing the labor in these labors of love.

Finally, the nursing home industry has a long history of aggressively collecting debts. During the 2007 Great Recession, states had to contend with increased demand for public programs like Medicaid, increased unemployment rates, and decreased tax revenues. This pressure generated renewed interest in filial responsibility laws, including a rise in lawsuits. As Medicaid grapples with recent funding cuts, it seems plausible that nursing homes’ efforts to collect outstanding debt will only intensify, lobbying lawmakers to use and expand legal authority already on the books.

Unpaid caregiving in the U.S. is valued at over half a trillion dollars per year, emphasizing the labor in these labors of love. We, like many of us, have our own stories of struggling to care for elderly family members while pursuing our careers and raising our own children. If adult children are required to fund nursing home care for their parents, it will only amplify that strain. Not to mention, it would jeopardize their own retirement and long-term care savings by diverting them to their parents.

Perhaps states with filial laws on the books will continue to ignore them, but as we have seen before, dormant laws have a way of being used when convenient. With Medicaid in the crosshairs in Washington, that time could very well be soon, making the repeal of these laws at the state level a concrete way to better protect families.

This post is in partnership with the Medicaid Policy Lab at Boston University School of Public Health. The views expressed here are the authors’ own and do not necessarily represent the views of Public Health Post or Boston University School of Public Health.