For years, Patricia Hunter showed up—again and again—to virtual meetings with members of Congress. Alongside other advocates from the Nursing Home Reform Coalition, she pressed lawmakers to confront one of the most persistent problems in long-term care: chronic understaffing in nursing homes.
That persistence finally seemed to pay off in 2023, when the Biden administration moved to address the issue head-on. Federal officials endorsed a Medicare rule that would establish minimum staffing levels for nursing homes, requiring facilities to provide at least 3.48 hours of care per resident each day and to have a registered nurse on site around the clock.
To advocates like Hunter, who leads Washington state’s long-term care ombudsman program, the proposal wasn’t perfect—but it mattered. “It wasn’t everything we hoped for,” she said, “but it was a solid first step. Having a federal standard would have made enforcement much stronger.”
What followed instead was a sweeping reversal that illustrates how Three Policy Changes That Could Reshape Health Care for Older Adults are now unfolding—often to the alarm of patient advocates.
Nursing Home Staffing: A Rule That Never Took Effect
When the Centers for Medicare & Medicaid Services (CMS) finalized the staffing standards in 2024, supporters celebrated what felt like a long-overdue victory. That optimism didn’t last.
Nursing home industry groups quickly filed lawsuits, and two federal district courts agreed that Medicare had overstepped its authority. The rulings stalled the regulation before it could be implemented.
After the 2024 elections, Hunter worried about what a shift in political leadership might mean. Those fears were confirmed months later. In July, Congress barred Medicare from enforcing the staffing rule until at least 2034 as part of Republicans’ “One Big Beautiful Bill Act.” Shortly afterward, CMS repealed the rule entirely.
“It was devastating,” Hunter said.
Consumer advocates argue that the rollback carries real consequences. Sam Brooks, public policy director for the National Consumer Voice for Quality Long-Term Care, said the repeal sends a clear signal. “CMS is stepping away from ensuring safe staffing,” he said, noting that researchers at the University of Pennsylvania estimated the rule could have prevented as many as 13,000 deaths annually.
Industry representatives counter that the mandate was unrealistic. Holly Harmon of the American Health Care Association said nursing homes are already grappling with severe workforce shortages. “The rule would have required hiring tens of thousands of caregivers who simply aren’t available,” she said, warning that some facilities would have been forced to reduce admissions or close altogether.
With the federal effort now stalled, advocates are shifting their focus to the 35 states—and Washington, D.C.—that already have staffing requirements, pushing for stronger enforcement and broader adoption.
Home Care Workers Lose Federal Labor Protections
Another major policy shift arrived unexpectedly in July, when the U.S. Department of Labor announced it would stop enforcing a decade-old rule that guaranteed minimum wage and overtime pay for home care workers.
To understand the impact, it helps to look backward. The Fair Labor Standards Act (FLSA), created during the New Deal, originally excluded most domestic workers. While that changed in 1975, home care workers were left out—largely because their work was wrongly viewed as informal or unskilled.
“It was treated like casual babysitting,” said Kezia Scales of PHI, a national research and advocacy group. “Not as the essential, professional care that it really is.”
After nearly 40 years of advocacy, the Labor Department reversed course in 2013, extending wage and overtime protections to home care workers. The rule survived industry challenges and remained in place for a decade, recovering millions in unpaid wages. A federal report later found that most complaints filed under the rule revealed violations.
Then came the reversal.
In July, the Labor Department announced it would return to the 1975 interpretation, arguing that the newer rule had limited access to care. Home care agencies—many funded through Medicaid—largely supported the change, saying states had capped work hours to avoid overtime costs, leaving workers with little benefit.
Still, advocates see the decision as a setback for a workforce made up largely of women, immigrants, and people of color. “It’s a shocking step backward,” Scales said, especially as Congress considers legislation that could cut Medicaid funding by more than $900 billion over the next decade.
Medicare’s New Experiment With AI Prior Authorization
The third shift could affect how millions of older adults receive care under traditional Medicare.
This month, CMS launched a pilot program called WISeR—short for Wasteful and Inappropriate Service Reduction—in six states. The initiative introduces prior authorization into traditional Medicare, using artificial intelligence and machine learning to review certain medical services before they are approved for payment.
Prior authorization is common in Medicare Advantage plans but has historically been rare in traditional Medicare. Under WISeR, tech vendors will evaluate requests for 17 services deemed at higher risk for waste or fraud, including some orthopedic procedures and medical devices.
CMS says the program excludes emergency care and promises that any automated denial will be reviewed by a licensed clinician. The vendors will receive a portion of the savings generated by denied claims.
That financial incentive worries critics.
“It brings the worst aspects of Medicare Advantage into traditional Medicare,” said David Lipschutz of the Center for Medicare Advocacy. He also warned that CMS could expand the program nationwide without congressional approval.
Lawmakers have already responded. Democrats introduced legislation to repeal WISeR, arguing that it adds unnecessary red tape to a system long valued for its simplicity. “We should be removing barriers to care, not adding new ones,” said Rep. Suzan DelBene of Washington.
For now, the pilot is live, with CMS promising annual public reports and independent evaluations.
A Turning Point for Aging Care in America
Together, these developments reflect Three Policy Changes That Could Reshape Health Care for Older Adults—from how nursing homes are staffed, to how home care workers are paid, to how Medicare decides what care it will cover.
For advocates like Patricia Hunter, the concern isn’t just about policy. It’s about the real people behind the rules. “Older adults deserve safe, reliable care,” she said. “And caregivers deserve to be supported—not pushed to the margins.”
Whether these changes become temporary detours or lasting transformations remains to be seen. But for now, the landscape of care for America’s aging population looks markedly different than it did just a few years ago.
