These 3 Policy Moves Are Likely To Change Health Care for Older People

Month after month, Patricia Hunter and fellow members of the Nursing Home Reform Coalition participated in video calls with congressional representatives, advocating for a proposed federal rule aimed at establishing minimum staffing levels for nursing homes.

After decades of relentless advocacy, the Biden administration finally addressed the long-standing issue of understaffing in long-term care facilities in 2023. Officials supported a Medicare regulation that would mandate a minimum of 3.48 hours of care from nurses and aides per resident each day, along with the requirement of having a registered nurse on-site 24/7.

While the mandated hours fell short of what supporters had hoped for, Hunter, who directs Washington state’s long-term care ombudsman program, expressed a pragmatic outlook: “This is a good start,” she remarked. “It would be helpful, for enforcement, to have a federal law.”

In 2024, when the Centers for Medicare & Medicaid Services (CMS) adopted these standards, advocates celebrated the progress. However, industry lawsuits quickly obstructed most of the rule, with two federal district courts determining that Medicare had overstepped its regulatory authority.

After the 2024 elections, Hunter voiced her concerns about potential changes in leadership, which unfortunately came to fruition.

In July, as part of the Republicans’ One Big Beautiful Bill Act, Congress prohibited Medicare from implementing the staffing standards until 2034. Just last month, CMS repealed the standards entirely, meaning they never took effect.

“It was devastating,” Hunter lamented.

Similar to the rollback of environmental laws and consumer protections, the Trump administration’s push for deregulation has dismantled long-sought rules aimed at enhancing care for the elderly. Additionally, it has introduced a Medicare experiment for prior authorizations in six states, raising alarms among advocates, congressional Democrats, and many older Americans.

These changes will significantly impact numerous facilities and workers providing care, complicating health coverage across several states.

On the nursing home front, “it’s clear CMS has no interest in ensuring adequate staffing,” stated Sam Brooks, director of public policy for the National Consumer Voice for Quality Long-Term Care.

“They’re repealing a regulation that could have saved 13,000 lives a year,” he added, referencing an analysis by researchers at the University of Pennsylvania.

Industry groups countered that nursing homes, already facing high staff turnover rates, were struggling to fill vacancies. The staffing mandate “would have required nursing homes to hire an additional 100,000 caregivers that simply don’t exist,” argued Holly Harmon, senior vice president at the American Health Care Association. “Facilities would have been forced to limit admissions or downsize to comply with the requirements, or close altogether,” she added.

For supporters, the focus is now likely to shift toward updating requirements in the 35 states and the District of Columbia that have already established some nursing home staff standards, as well as developing them in states that have not yet done so.

Rules for Home Help

A second rescinded regulation, which took many by surprise, occurred in July when the Labor Department announced a return to a policy excluding home care workers from the federal Fair Labor Standards Act.

Historically, the FLSA mandated that workers receive the federal minimum wage (currently $7.25 an hour) and overtime pay. It exempted most “domestic service workers” until 1975, when a new Labor Department regulation included them—except for home care workers.

“There was a misinterpretation of home care work as being casual, nonprofessional, non-skilled,” explained Kezia Scales, vice president at PHI, a national research and advocacy organization. “Just someone popping into your mother’s house now and then and keeping her company.”

For nearly 40 years, workers and their supporters lobbied for a change, viewing the rule as a contributor to the low wages and scant benefits of a rapidly growing workforce, predominantly composed of women and minority groups, many of whom are immigrants.

In 2013, the Labor Department responded with a rule that brought home care workers under the labor act, ensuring they received minimum wage, overtime pay, and compensation for travel time between clients.

After industry lawsuits failed to overturn it, “everything settled down,” Scales noted. “It was in place successfully for a decade.”

Home care workers filed hundreds of compliance complaints annually, with the Labor Department finding violations of the labor act in 87% of those cases, according to a 2020 Government Accountability Office report.

Since 2013, home care agencies have paid approximately $158 million in back wages, as calculated by PHI.

However, in July, the Labor Department abruptly announced a return to the 1975 regulations and stopped enforcing the 2013 rule, claiming it had “negative effects on the ground” and hindered consumer access to care.

The agencies employing most home care workers, primarily funded through Medicaid, agreed. “Many workers never got any benefit from this,” stated Damon Terzaghi, vice president at the National Alliance for Care at Home.

“States made a lot of moves to essentially absolve themselves of any responsibility,” he added. A 2020 federal report found that 16 states had capped Medicaid-covered home care hours at 40, thus avoiding overtime payment.

The alliance estimates that the number of impacted agencies and businesses has declined by 30% since 2013, supporting the rescission. Scales, however, called it “a shocking step backward,” hoping for congressional action.

Where both sides agree is that the United States has never truly committed to adequately funding long-term care at home. With July’s legislation paving the way for a $914 billion cut to Medicaid over the next decade, significant changes seem unlikely.

Medicare’s AI Referee

In addition to rolling back policies for elderly care, the Trump administration has initiated a pilot program to introduce prior authorization into traditional Medicare, utilizing artificial intelligence and machine learning technologies.

Promoted as a benefit to taxpayers, Medicare has dubbed it WISeR—Wasteful and Inappropriate Service Reduction.

Prior authorization, a process where private insurers review proposed treatments before agreeing to pay for them, is common in Medicare Advantage plans, despite its unpopularity among patients, doctors, and healthcare organizations. It has rarely been applied in traditional Medicare.

This month, however, WISeR launched in six states (Arizona, New Jersey, Ohio, Oklahoma, Texas, Washington) as a six-year trial to assess whether tech companies can reduce costs and improve efficiency while maintaining or enhancing care quality.

Initially, WISeR targets 17 items and services that CMS identified as historically prone to waste, fraud, and abuse. This list includes knee arthroscopy for arthritis, electrical nerve stimulation devices for various conditions, and treatments for impotence.

The pilot program excludes emergency services and inpatient hospital care, or any care where delay poses “a substantial risk.” Algorithmic denials will trigger a review by “an appropriately licensed human clinician.” The tech companies involved will receive “a share of averted expenditures.”

“It injects some of the worst of Medicare Advantage into traditional Medicare,” criticized David Lipschutz, co-director of the Center for Medicare Advocacy. He pointed out that the six vendors responsible for approving or denying treatments “have a financial stake in the outcomes,” creating an incentive to deny care.

Moreover, the CMS Innovation Center overseeing the pilot could theoretically bypass Congress and expand prior authorization to include more medical services in additional states.

The agency has not responded to inquiries about the qualifications of the human clinicians reviewing denials, only stating that they would have “relevant experience” and that tech companies would face “financial penalties for inappropriate denials, high appeal rates, or poor performance.”

CMS plans to conduct an “independent, federally funded evaluation” and will release public reports annually.

Democrats in Congress have introduced bills in both houses to repeal WISeR. “We should be reducing red tape in Medicare, not creating new hurdles that second-guess healthcare providers,” stated Rep. Suzan DelBene of Washington, one of the bill’s sponsors.

For now, however, WISeR is operational, receiving prior authorization requests through its electronic portals.

“The New Old Age” is produced through a partnership with The New York Times.

Month after month, Patricia Hunter and fellow members of the Nursing Home Reform Coalition participated in video calls with congressional representatives, advocating for a proposed federal rule aimed at establishing minimum staffing levels for nursing homes.

After decades of relentless advocacy, the Biden administration finally addressed the long-standing issue of understaffing in long-term care facilities in 2023. Officials supported a Medicare regulation that would mandate a minimum of 3.48 hours of care from nurses and aides per resident each day, along with the requirement of having a registered nurse on-site 24/7.

While the mandated hours fell short of what supporters had hoped for, Hunter, who directs Washington state’s long-term care ombudsman program, expressed a pragmatic outlook: “This is a good start,” she remarked. “It would be helpful, for enforcement, to have a federal law.”

In 2024, when the Centers for Medicare & Medicaid Services (CMS) adopted these standards, advocates celebrated the progress. However, industry lawsuits quickly obstructed most of the rule, with two federal district courts determining that Medicare had overstepped its regulatory authority.

After the 2024 elections, Hunter voiced her concerns about potential changes in leadership, which unfortunately came to fruition.

In July, as part of the Republicans’ One Big Beautiful Bill Act, Congress prohibited Medicare from implementing the staffing standards until 2034. Just last month, CMS repealed the standards entirely, meaning they never took effect.

“It was devastating,” Hunter lamented.

Similar to the rollback of environmental laws and consumer protections, the Trump administration’s push for deregulation has dismantled long-sought rules aimed at enhancing care for the elderly. Additionally, it has introduced a Medicare experiment for prior authorizations in six states, raising alarms among advocates, congressional Democrats, and many older Americans.

These changes will significantly impact numerous facilities and workers providing care, complicating health coverage across several states.

On the nursing home front, “it’s clear CMS has no interest in ensuring adequate staffing,” stated Sam Brooks, director of public policy for the National Consumer Voice for Quality Long-Term Care.

“They’re repealing a regulation that could have saved 13,000 lives a year,” he added, referencing an analysis by researchers at the University of Pennsylvania.

Industry groups countered that nursing homes, already facing high staff turnover rates, were struggling to fill vacancies. The staffing mandate “would have required nursing homes to hire an additional 100,000 caregivers that simply don’t exist,” argued Holly Harmon, senior vice president at the American Health Care Association. “Facilities would have been forced to limit admissions or downsize to comply with the requirements, or close altogether,” she added.

For supporters, the focus is now likely to shift toward updating requirements in the 35 states and the District of Columbia that have already established some nursing home staff standards, as well as developing them in states that have not yet done so.

Rules for Home Help

A second rescinded regulation, which took many by surprise, occurred in July when the Labor Department announced a return to a policy excluding home care workers from the federal Fair Labor Standards Act.

Historically, the FLSA mandated that workers receive the federal minimum wage (currently $7.25 an hour) and overtime pay. It exempted most “domestic service workers” until 1975, when a new Labor Department regulation included them—except for home care workers.

“There was a misinterpretation of home care work as being casual, nonprofessional, non-skilled,” explained Kezia Scales, vice president at PHI, a national research and advocacy organization. “Just someone popping into your mother’s house now and then and keeping her company.”

For nearly 40 years, workers and their supporters lobbied for a change, viewing the rule as a contributor to the low wages and scant benefits of a rapidly growing workforce, predominantly composed of women and minority groups, many of whom are immigrants.

In 2013, the Labor Department responded with a rule that brought home care workers under the labor act, ensuring they received minimum wage, overtime pay, and compensation for travel time between clients.

After industry lawsuits failed to overturn it, “everything settled down,” Scales noted. “It was in place successfully for a decade.”

Home care workers filed hundreds of compliance complaints annually, with the Labor Department finding violations of the labor act in 87% of those cases, according to a 2020 Government Accountability Office report.

Since 2013, home care agencies have paid approximately $158 million in back wages, as calculated by PHI.

However, in July, the Labor Department abruptly announced a return to the 1975 regulations and stopped enforcing the 2013 rule, claiming it had “negative effects on the ground” and hindered consumer access to care.

The agencies employing most home care workers, primarily funded through Medicaid, agreed. “Many workers never got any benefit from this,” stated Damon Terzaghi, vice president at the National Alliance for Care at Home.

“States made a lot of moves to essentially absolve themselves of any responsibility,” he added. A 2020 federal report found that 16 states had capped Medicaid-covered home care hours at 40, thus avoiding overtime payment.

The alliance estimates that the number of impacted agencies and businesses has declined by 30% since 2013, supporting the rescission. Scales, however, called it “a shocking step backward,” hoping for congressional action.

Where both sides agree is that the United States has never truly committed to adequately funding long-term care at home. With July’s legislation paving the way for a $914 billion cut to Medicaid over the next decade, significant changes seem unlikely.

Medicare’s AI Referee

In addition to rolling back policies for elderly care, the Trump administration has initiated a pilot program to introduce prior authorization into traditional Medicare, utilizing artificial intelligence and machine learning technologies.

Promoted as a benefit to taxpayers, Medicare has dubbed it WISeR—Wasteful and Inappropriate Service Reduction.

Prior authorization, a process where private insurers review proposed treatments before agreeing to pay for them, is common in Medicare Advantage plans, despite its unpopularity among patients, doctors, and healthcare organizations. It has rarely been applied in traditional Medicare.

This month, however, WISeR launched in six states (Arizona, New Jersey, Ohio, Oklahoma, Texas, Washington) as a six-year trial to assess whether tech companies can reduce costs and improve efficiency while maintaining or enhancing care quality.

Initially, WISeR targets 17 items and services that CMS identified as historically prone to waste, fraud, and abuse. This list includes knee arthroscopy for arthritis, electrical nerve stimulation devices for various conditions, and treatments for impotence.

The pilot program excludes emergency services and inpatient hospital care, or any care where delay poses “a substantial risk.” Algorithmic denials will trigger a review by “an appropriately licensed human clinician.” The tech companies involved will receive “a share of averted expenditures.”

“It injects some of the worst of Medicare Advantage into traditional Medicare,” criticized David Lipschutz, co-director of the Center for Medicare Advocacy. He pointed out that the six vendors responsible for approving or denying treatments “have a financial stake in the outcomes,” creating an incentive to deny care.

Moreover, the CMS Innovation Center overseeing the pilot could theoretically bypass Congress and expand prior authorization to include more medical services in additional states.

The agency has not responded to inquiries about the qualifications of the human clinicians reviewing denials, only stating that they would have “relevant experience” and that tech companies would face “financial penalties for inappropriate denials, high appeal rates, or poor performance.”

CMS plans to conduct an “independent, federally funded evaluation” and will release public reports annually.

Democrats in Congress have introduced bills in both houses to repeal WISeR. “We should be reducing red tape in Medicare, not creating new hurdles that second-guess healthcare providers,” stated Rep. Suzan DelBene of Washington, one of the bill’s sponsors.

For now, however, WISeR is operational, receiving prior authorization requests through its electronic portals.

“The New Old Age” is produced through a partnership with The New York Times.