Month after month, Patricia Hunter and other members of the Nursing Home Reform Coalition logged onto video calls with congressional representatives, seeking support for a proposed federal rule setting minimum staff levels for nursing homes.
Finally, after decades of advocacy, the Biden administration in 2023 tackled the problem of perennial understaffing of long-term care facilities. Officials backed a Medicare regulation that would mandate at least 3.48 hours of care from nurses and aides per resident, per day, and would require a registered nurse on-site 24 hours a day, seven days a week.
The mandated hours were lower than supporters hoped for, said Hunter, who directs Washington state鈥檚 long-term care ombudsman program. But 鈥淚鈥檓 a pragmatic person, so I thought, this is a good start,鈥 she said. 鈥淚t would be helpful, for enforcement, to have a federal law.鈥
In 2024, when the Centers for Medicare & Medicaid Services adopted the standards, advocates celebrated. But industry lawsuits soon blocked most of the rule, with two federal district courts finding that Medicare had exceeded its regulatory authority.
And after the 2024 elections, Hunter said, 鈥淚 was concerned about the changing of the guard.鈥 Her concerns proved well founded.
In July, as part of Republicans鈥 One Big Beautiful Bill Act, Congress prohibited Medicare from implementing the staffing standards before 2034. Last month, CMS altogether. They never took effect.
鈥淚t was devastating,鈥 Hunter said.
As with environmental law and consumer protections, the Trump administration鈥檚 enthusiasm for deregulation has undone long-sought rules to improve care for the aged. And it has introduced , now getting underway in six states, that has alarmed advocates, congressional Democrats, and a good number of older Americans.
Taken together, the moves will affect many of the facilities and workers providing care and introduce complications in health coverage in several states.
On the nursing home front, 鈥渋t鈥檚 clear CMS has no interest in ensuring adequate staffing,鈥 said Sam Brooks, the director of public policy for the National Consumer Voice for Quality Long-Term Care.
鈥淭hey鈥檙e repealing a regulation that could have saved 13,000 lives a year,鈥 he added, citing by University of Pennsylvania researchers.
Industry groups argued that nursing homes, with high rates of staff turnover, were already struggling to fill vacancies.
The staffing mandate 鈥渨as requiring nursing homes to hire an additional 100,000 caregivers that simply don鈥檛 exist,鈥 said Holly Harmon, a senior vice president at the American Health Care Association.
The organization had brought one of the suits that largely vacated the rule. 鈥淔acilities would have been forced to limit admissions or downsize to comply with the requirements, or close altogether,鈥 Harmon said.
For supporters, the action is now likely to shift to updating requirements in 35 states, along with the District of Columbia, that have already established , and to developing them in those that haven鈥檛.
Rules for Home Help
A second rescinded regulation, this one more unexpected, brought about upheaval in July, when the Labor Department announced a return to from the federal Fair Labor Standards Act.
Some history: Dating back to the New Deal, the FLSA mandated that workers receive the federal minimum wage (currently $7.25 an hour) and overtime pay. It exempted most 鈥渄omestic service workers鈥 until 1975, when a new Labor Department regulation included them 鈥 with the exception of home care workers.
鈥淭here was a misinterpretation of home care work as being casual, nonprofessional, non-skilled,鈥 the equivalent of teenage babysitting, said Kezia Scales, a vice president at PHI, a national research and advocacy organization. 鈥淛ust someone popping into your mother鈥檚 house now and then and keeping her company.鈥
For almost 40 years, workers and their supporters lobbied to change the rule, seeing it as a contributor to the low wages and meager benefits of a swiftly growing workforce, one made up primarily of women and minority groups, with many immigrants.
In 2013, the Labor Department responded with a rule that , entitled to minimum wage, time and a half for overtime work, and payment for travel time between clients.
After industry lawsuits failed to overturn it, 鈥渆verything settled down,鈥 Scales said. 鈥淚t was in place successfully for a decade.鈥
Home care workers brought hundreds of compliance complaints annually. In 87% of them, the Labor Department found , according to a 2020 Government Accountability Office report.
Since 2013, home care agencies have paid about , PHI has calculated.
Then in July, the Labor Department abruptly announced that it would return to the 1975 regulations and , which it said 鈥渉ad negative effects on the ground鈥 and hindered consumer access to care.
The agencies employing most home care workers, primarily funded through Medicaid, would agree. 鈥淢any workers never got any benefit from this,鈥 said Damon Terzaghi, a vice president at the National Alliance for Care at Home.
鈥淪tates made a lot of moves to essentially absolve themselves of any responsibility,鈥 he said. A 2020 federal report, for example, found that 16 states had at 40, thus averting overtime payment.
The alliance, which estimates that the number of impacted agencies and businesses has declined by 30% since 2013, supported the rescission. Scales, who hopes for congressional action, called it 鈥渁 shocking step backward.鈥
Where they concur is that the United States has never really committed to sufficiently funding long-term care at home. With the July legislation setting the stage for a over the coming decade, that seems unlikely to change anytime soon.
Medicare鈥檚 AI Referee
Beyond rolling back policies for care of the aged, the Trump administration has established a pilot program to introduce one to traditional Medicare: prior authorization, using artificial intelligence and machine learning technologies.
Touting it as a boon to taxpayers, Medicare calls it WISeR 鈥 Wasteful and Inappropriate Service Reduction.
, in which private insurers review proposed treatments before agreeing to pay for them, is widely used in Medicare Advantage plans despite its unpopularity with patients, doctors, and health care organizations. It has rarely been used in traditional Medicare.
This month, however, in six states (Arizona, New Jersey, Ohio, Oklahoma, Texas, Washington) in a six-year trial to determine whether review by tech companies can reduce costs and improve efficiency, while maintaining or improving quality of care.
Initially, that CMS said 鈥渉istorically have had a higher risk of waste, fraud and abuse.鈥 The list includes knee arthroscopy for arthritis, electrical nerve stimulation devices for several conditions, and treatment for impotence.
The pilot program excludes emergency services and inpatient hospital care, or care where delay poses 鈥渁 substantial risk.鈥 Algorithmic denials will trigger review by 鈥渁n appropriately licensed human clinician.鈥 The tech companies get 鈥渁 share of averted expenditures.鈥
鈥淚t injects some of the worst of Medicare Advantage into traditional Medicare,鈥 said David Lipschutz, co-director of the Center for Medicare Advocacy. The six vendors that approve or reject treatments 鈥渉ave a financial stake in the outcomes,鈥 he said, and therefore 鈥渁n incentive to deny care.鈥
Moreover, the CMS Innovation Center overseeing the pilot could theoretically bypass Congress and expand prior authorization to include more medical services in more states.
The agency did not respond to questions about what kind of human clinicians would review denials, except to say that they would have 鈥渞elevant experience鈥 and that tech companies would be 鈥渇inancially penalized for inappropriate denials, high appeal rates or poor performance.鈥
It plans an 鈥渋ndependent, federally funded evaluation鈥 and will release public reports annually.
Democrats in Congress have in both houses to repeal WISeR. 鈥淲e should be reducing red tape in Medicare, not creating new hurdles that second-guess health care providers,鈥 said Rep. Suzan DelBene of Washington, one of the bill鈥檚 sponsors.
For now, though, WISeR has opened for business, receiving prior authorization requests through its electronic portals.
鈥淭he New Old Age鈥 is produced through a partnership with .
