ICYMI: A Message from Mark Parkinson: The Recovery Continues

A Message from AHCA/NCAL President & CEO Mark Parkinson

2023: The Recovery Continues

Happy Holidays from the AHCA/NCAL Team

When I think about 2023, I am grateful and proud. AHCA/NCAL state executives and members have continued to step up in many ways, and we remain united. Before I discuss 2023 in more detail, I want to take a moment to highlight the 2023 Annual Report. This document outlines the Association’s overarching goals and strategies over the past 12 months, as well as our success and achievements.

Much of this is also thanks to the hard work and dedication of the smiling faces you see above. We couldn’t do it without you, our members. The entire staff at AHCA/NCAL thanks you for your ongoing support and wishes you a happy, healthy holiday season.


Four years ago, the world recorded its first case of COVID-19, and our world changed forever.  That year, 2020, had everything negative possible – fear, despair, and death. But it also had faith, hope, and heroism. The year was both our worst time ever and our finest hour.

Since then, we’ve been slowly recovering. That recovery continued in 2023, but we’re not home yet. Most importantly, the pandemic is over. We’ve had COVID flare ups throughout the year, but hospitalizations and mortality remained low.

You’ve done a remarkable job at caring for residents who got COVID, and the clinical nightmare is behind us. Unfortunately, the business challenges continue. While census has continued to recover, the recovery has been painstakingly slow, and we are not back to pre-pandemic census levels.

If we can continue at this pace, we will see a complete recovery in 2024. Because of favorable demographics, I believe we will then continue to climb.

The labor shortage is also an unfortunate challenge. We can’t find enough workers to staff our buildings at the same levels we saw pre-pandemic. This is why census may be struggling—we can’t serve as many residents when we can’t find workers. While there has been some recovery, we are still facing an unprecedented worker shortage.

It is encouraging that we’ve had some recovery, even when it has been slow. At this pace, it will take until the end of 2025 for us to reach pre-pandemic job levels.


Faced with these realities, it is shocking that any of us are still around. Unfortunately, some are not. The pace of nursing home closures has accelerated. There have been 600 SNF closures and almost 50,000 licensed beds that operators have shuttered since the start of the pandemic.

Even those that have not closed have struggled. Every year, the Medicare Payment Advisory Commission (MedPAC) does an analysis of skilled nursing margins, and it just released the 2023 report that indicated all-in margins (including Medicare and Medicaid) are -1.8%. The average nursing home is losing money.

Fortunately, we have had some success in 2023 that we hope will start to turn those numbers around. For the 12th year in a row, we received a Medicare increase. This year’s increase of 4% is the largest increase we’ve had in a decade. Just as important, this increase also puts all the Patient Driven Payment Model (PDPM) adjustment issues behind us. We’re pleased to have had this success at the federal level.

But the real heroes in 2023 were once again our state affiliates and the state executives who lead them. The past 12 months marked another year where multiple states achieved record Medicaid increases. These did not occur by accident. We have a terrific group of state executives, and they collectively hit it out of the park in 2023.

Our hope for 2024 is that we can continue to keep the increases coming. We’re planning on another Medicare increase, but it won’t be easy. In the same report that MedPAC reported our negative margin, it recommends that CMS cut our Medicare rates by 3%! We’re not going to let that happen, and it is safe for you to plan on another Medicare market basket increase on October 1 of 2024.

We are also hopeful that the states can replicate their success in 2024. You’re probably aware that for the last five years, AHCA/NCAL has actively partnered with state efforts to increase Medicaid. The states deserve the credit for the increases they have achieved, but we’ve been thrilled to be a part of it. Once again, the AHCA Board – led by Phil Scalo – has committed millions of dollars to this program in 2024.


It is more than slightly annoying that as the sector continues to try to recover from the pandemic, we’ve had to spend so much time fighting the proposed minimum staffing rule. But we must. It’s impossible for most members to implement, and the penalties are ridiculous. The rule, as written, would be “lights out” for thousands of nursing homes.

We won’t let that happen. But to keep it from happening, we have to continue to give it everything we have.

Members were incredible on this issue in 2023. Collectively, you submitted 18,150 comments opposing the rule. 18,150! And along the way, we had record attendance at Congressional Briefing, a record number of facility tours, and year-round visits to Capitol Hill. On top of that, the member dues you provide the Association has allowed us to run continuous media campaigns blasting the rule.

It’s starting to work. Bipartisan letters from the House and Senate have gone to the Administration opposing the rule. Bipartisan legislation has been introduced that would prevent the rule from being finalized. Multiple legislative efforts are in planning to go after the rule, and we will execute them.

But we can’t stop now. We must keep going. Every day. Every single day. In 2024, we’re going to again need you to invite members of Congress to tour your buildings. We’re going to need you in Washington, D.C. for Congressional Briefing in June and throughout the year. We will provide updates as we need your help, and you can sign up to receive action alerts on the AHCA/NCAL website. You can also reach out to Heather Posthumus and Matt Smyth if you need assistance or have questions about hosting congressional tours.

Here is the good news. If we keep this pressure going, we will win this issue. On top of that, the issue has exposed members of Congress to our buildings that have never been involved with us before. We’re going to come out of this with a Congress that understands us better than we’ve ever had. We’re going to come out of it with new friends on Capitol Hill and a handful of champions. This fight is going to make us better.

But we must keep pounding away, and we will.


The news for assisted living has all been good. First, concerns about federal regulation of assisted living haven’t materialized. The Administration has been so focused on skilled nursing, and it hasn’t had time for assisted living. There have been no new burdensome regulations. In addition, the Hill has also been hands off.

This has allowed the NCAL Board and staff to focus on new projects to move the profession forward. One of the most exciting projects is the Assisted Living State Regulatory Resource Center. NCAL will soon offer members the first nationwide tool to find state-by-state regulations, survey patterns, and proposed legislation. We’re excited to roll this out in 2024.

NCAL was also very focused on affordable assisted living in 2023. The team developed a white paper outlining the issue and proposed solutions to help support this important effort. They also created materials to assist providers in exploring the viability of expanding affordable assisted living options, including state-specific data, the Assisted Living Operating Proforma and Financial Feasibility Analysis Model, and a user guide for the financial model. This is an important issue for NCAL and will continue to be a focus in 2024.


Three additional important AHCA/NCAL offerings were developed in 2023. Our senior living Group Purchasing Organization (GPO) continues to exceed expectations. Multiple members have learned that the GPO can save them considerable dollars on food and other everyday purchases, and more members are joining each week. This is a true win-win because the revenue that we receive from the GPO is cycled back into AHCA/NCAL and the states for legislative activity. We’re saving money for members and becoming stronger advocates at the same time. We encourage you to learn more about this savings opportunity if you haven’t already done so.

This was also a year of continued growth of the provider-owned networks we help our members develop. We’re as frustrated with the challenges of managed care as you are, and we’re continuing to work with you as we determine ways to overcome these challenges. One of the most effective has been our effort to create state networks. We started with our first in Iowa in 2020. We now have eight, with six expected to launch in 2024. We anticipate continued growth of the program over the next several years as additional states get involved.

Additionally, with funding from the CDC, we launched the National Infection Prevention Forum. This is an online forum for infection preventionist to share their experiences, ask questions, and hear timely updates about infection prevention. We have over 1,000 Infection Preventionists participating to date. You can contact our team to find out more and join this effort. Don’t forget that AHCA/NCAL also offers Infection Preventionist Specialized Training (IPCO), which is recommended for individuals responsible for infection prevention and control in LTC communities. You can learn more on ahcancalED.


In addition to 2023 being the year of the state executives, it was also the year of our members.  You really shined, first and foremost for the work that you do every day in your buildings. But also, for the work you’ve done with AHCA/NCAL.

I’ve already discussed the massive grassroots work members performed. Equally impressive is your work on the National Quality Award Program. As expected, applications for Quality Awards dropped drastically in 2021 and 2022. You all were fighting for your residents’ lives, and we understood that this program had to take a back seat. But we saw a massive turnaround in 2023 and will see an even bigger one in 2024.

We set a goal of increasing Quality Award Intent to Apply submissions by 5% in 2023, and you completely blew that away. This includes a record number of both nursing homes and assisted living communities since the beginning of the pandemic, which is a huge success.

We are poised to have an incredible turnout of applications in 2024 as we go back to pre-pandemic levels. Based on the Intent to Apply process, 1,640 buildings are interested in participating.


This has been another year where my main emotion is gratitude. I am deeply grateful for you, our AHCA/NCAL team, and the opportunity to do this work. Our leadership, headed by Phil Scalo, continues to provide us the guidance and resources to get the job done. With those resources, we’ve been able to hire the best and the brightest, and I love working with them every day. Both you and they inspire me to be my best – because I don’t want to let you or them down.

To have this opportunity, for a cause I believe in so deeply, is a gift that I will never take for granted.

Thanks so much. Have a great holiday, and then let’s go out and crush it in 2024!


Mark Parkinson
President & CEO